Chen NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesotn Stn�e Stnn�re-166.05 states tlutt "...every person...who claims damages from any municipaliry...shall cae�se to be presented to the
gnvei-ning bo�v nf the niunrcipaliry witl7in 180 day.r after the alleged loss or injury is discovered a notice stating the time,place,ancl
eircumsta�lces thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �GI 0 Middle Initial Last Name C h�h
Company or Business Name
Are You an Insurance Company? Yes/�'Q If Yes, Claim Number?
Street Address �3�'3 ��r�S����L'� S-� /�� 3
City J� ' ��u � State ��� Zip Code � � (�g
Daytime Phone ( �� L) �Z� ��1 Cell Phone ( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered� Z 6 � z o�� Time�Z �ri/pm
Please state, in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
`� w 0 r' �e �gw�er �evt c. b (� �
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Please check the box(es) that most closely represent the reason for completing this form:
O My vehicle was damaged in an accident �My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
� My ve�iicle w as wrongfully towed ancUor ticketed � I wa� injured on City property
❑ Other rype of property damage—please specify
❑ Other t�pe of injury—please specify
In order to process your claim you need to include copies of all apqlicable documents.
For the claims types listed below, please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or��b}�ls,��+
and/or receipts for the repairs; detailed list of damaged items � vC�1� U
O Injury claims: medical bills, receipts �q� 03 2�14
O Photographs are always welcome to document and support your claim but will not be returne .
Page 1 of 2—Please complete and return both pages of Claim Form C�TY CLERK
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section
Were there witnesses to the incident? Yes No Unkno�•n (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called`' Yes i�o L'nkno��n (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address, cross street. intersection, name �f park c►r facilit�.
closest landmark, e c. Please be as detailed as possible. If necessary, attach a diagram. z33 �' R�ew��ex �
Please indicate the amount you are seeking in compensation or��hat you w�ould like the Cit� tc,�i�, a, re:c�l��e thi. elaim
to your satisfaction.
Vehicle Claims—please com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year i Make i Model n ra
License Plate Number State�Color
Registered Owner
Driver of Vehicle Gru o �
Area Damaged �,:�,1� N��r�or
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section ❑ check bor if this section does not appl��
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Plannin� to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? �pro��ide date(c►1
Name of your Employer:
Address Telephone
� Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be proeessed.
Submitting a false claim can result in prosecution. Date form was completed f Z/�` ( /��3
Print the Name of the Person who Completed this Form: �k o C�I�h
Signature of Person Making the Claim: �
Revised February 201 1
UNIVERSITY SERVICE ESTIMATE#
1625 COMO AVE SE
MINNEAPOLIS, MN. 55414 021173
Phone-612-331-7587 Fax-952-426-3369
ESTIMATE FOR SERVICES cust i�: o Estimate Date : 12/27/2013
1999 Nissan - Sentra SE -
Lic#: 634MAT- Odometer In: 0
Unit# :
VIN# :
,.� �,
Part Descript�on f Number ` Qty Sale Extended Labor;Description ; , , : � , '�:��Extendecl���;;
DOOR MIRROR� - emove� ep ace- 59.40
96302-4B010 1.00 218.40 218.40 Applicable Models
PAINT MIRROR 75.00
Shop Supplies 12.35
Parts: 230.75 Labor: 134.40 Tax: 17.88 Total: $ 383.03
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees
permission to operate the vehicle described for testing and/or inspection. Express mechanic's lien is hereby acknowledged on above vehicle
to secure the amount of repairs thereto. SMOG: I understand that I can have emission service and/or adjustments done elsewhere. I hereby
waive this right.
TEARDOWN ESTIMATE: I understand that my vehicle will be reassembled within days of the date shown above if I choose not to
authorize the service recommended.All Parts removed will be discarded unless instructed otherwise: Save all Parts . NOT
RESPONSIBLE FOR LOSS OR DAMAGE TO CARS OR ARTICLES LEFT IN CARS IN CASE OF FIRE,THEFT O'Re NY OTHER CAUSE.
Signature Date
Page 1 of 1 Copyright(c)2013 Mitchell Repair Information Company,LLC esthrs 09.12.1 NKYK
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CITATION '
State of Minnesota Ramsey District Court �
Ciry of
? Citation# I IIIIII III�IIIII IIIII IIII)I'lll IIIII IIIII IIIII(�III IIII)(IIII IIII IIII
' 620900201755 620900201755 �
� DL Number State �
❑MN ❑CDL �
, Name i
First Middle Last �
Address— Street, Apt# �
,
Ciry State Zip �
DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity !
� Vehicle License No. Plate Year State ake Type Model Color +
I 1
;� Date of Offense Time of Offense ❑AcadenUCrash �
i d Property ❑Injury ❑Fatal ❑Pedestrian � (
Parking Meter Number Neighborhood Code ❑ HousinglBuilding Code N �
� �
' ❑Booked ❑Park/Operate ❑Owner ❑Passenger ❑Driver � j
� �
Offense Location �
N
NO1 Offef1S2 Statute/Ordinance � �
�
� �
NO 2 Offef1S2 Statute/Ordinance � �
� �
, i
No 3 Offense Statute/Ordinance f
' ❑Speed 169.14(subd ): mph zone j
a ❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) �
�' AC Taken—AC: Test type: ❑ Refused ❑ Breath ❑ Blood ❑ Urine ?
� �❑Hazardous Material (D0� ❑Unsafe Conditions ❑School Zone
❑Endangering Life& Property ❑Work Zone ❑Commercial Veh. DOT# ;
Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other �
; See back of citation for information on paying your fine. �
If cited for No Proof of Insurance or No Driver's License in Possession, Proof of Insurance and/or {
Driver's License must be shown at one of the Violations Bureau locations Iisted on the back of this ;
- citation within 21 days from the date the citation is filed with the Court. `
Please read the back of this citation carefully and respond. �
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Officer(s)Name(s) j
,
Officer No(s). '".. CN# Citing Dept ±
How Issued ❑In Person ❑Mailed ❑Leftat Scene
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