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Weiss NOTIC� OF CLAIM F�RM to the City of Saint Paul, Minnesota Mi�ureso[a S1u(e Stutute 466.05 stnles thnt "...everY person...�vhu clninrs dcuna�es fron�ariv rriu�iicipn[ity...sl�all cnuse ro he pre.sented to�he go��ernirig body of the ntur�icipa/ity wi[hin 180 duVS nfter tl�e allegetl loss or injurv is discovered a notice stnting tMe time,place,arTd circums7ances therenf,nnd tl�e nmoeutt q�contpensatinn or nther relief dentnndc:d." Please complete this form in its entirety by clearly typing or printing your answer to each question. It'more space is needed,attach additional sheets. Please note thxt 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 ctaim. This Form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name ►J'l�.�11�� Middle Initial_�Last Name��SS Companv or Business Name _ _ _ �____ __ _ �C��`/��f Are You an Insurance Company? es/No If Yes, Claim Number? .IAN !1R �n14 Street Address ��lA� � � ��'�r '` ��• City� �'�� State / �t /f Zip Code �/o K Daytime Phone (��.�1 )��-�Cell Phone (��)�� - 6�� Evening Telephone( ) - Date of Accident/Injury or Date Discovered_�1�� 1 �� Time `�'�� am pm Please state, in detail, what occurred (happened), and why you are submitting a claim. Please�dicate w y or how y feel the City �f S• �nt Paul r its einployees e involve�,,1fnd/or.�esponsible for your, amages. � " �� a ��t- ��, .,� �t /Ltk� u�r�.� �0�WI:�o�Sjr� ��.Cc��trv��K��O�L ��J�J s � � .6 .i � � �� e � _ � � -l� v Please check the box(es) that most closely represent the reason for completing this form: � 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 vehicle was wrongfully towed and/or ticketed ❑ I was injured on ity properfy - ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim�{ou need to include copies of all applicable 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 5500.00; 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 the actual bills and/or receipts for the repairs; detailed]ist of damaged items O Injury claims: medical bills, receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form I'ailure to complete and return both pages will result in delay in the handling of your claim. All Claims—please complete this section Were ther�uv.itne��s to,tt�i��i�nt'? Ye� No Unknown (circle) .�Provide t6ei`r`n�tn��;'�c'�`dt"��es�"��'�t lephone numbers: � ��tS�►� C��/e� /��5 i.A A J� 6Sl-L- y 4-Y tS� � Were the police or law enforcement called'? Yes (,�I�o Unknown (cirrlel If yes, what department or agency? Case #or report# Where did the accident or injury take place? Provide street address,cross street, intersection ame uf park or facility, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. A Please indicate the amount �re see �ng � compensat�o or what you woul like the Cit� to do t resol�e thi.rlaim �� to your atisfaction. "=�S � . Vehicle Claims—please compiete this section" �cfiec�: c�K--iT�fis �ec ��i i�n c,e< n�, ;,Pr ` Your Vehicle: Year Make Model T�� License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged In"ur Claims— lease com lete this section check bc�x if this section does nc>t a I� How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment (circle) When did you receive treatment? (provide date(s)1 Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No -- __ �!�]en_�ld v�L �� w�rk� - - - ��ate{s)? Name of your Employer: Address Telephone �Check here if you are attaching more pa es to this clai orm. Number of ad itional pag��s Z � C'�� L�..�c� By signing tltis form,you are stating tltat ull infor hl�i:you liave provided is tr re aird correct to tlie best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed � � Print the Name of the Person whu Complete his Form: �.�.�1� V�( Signature of Person Making the Claim: Revised February 201 I , ( � ' CITATION State of Mfnnesota Ramsey Distrfct Court City of '� �`�F � I I�� _ ; ' ::s:.::i0r# ' �II��IIN/�� 620900205331 620900205331 � DL Number State � ❑MN O CDL Name f Flrst Middle Last j Address—Street, Apt# � City State rp � I DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity � Vehicl License No. Plate Y ar tate M e Type Color ; C �a I Date of nse Ti e of ' enNCrash � ., w. ❑PropeAy ❑Injury ❑Fatal ❑Pedestrian � � Parking Meter Number Neigh rhood Code ❑ HousingBuilding Code N � ' ❑Booked perate ❑Owner ❑Passenger ❑Driver � ; Offense o 'on j � � � ,[" Y,�M1<' `��Z!'%. F:. IV � No 1 Offens � - s� , ^., � � ; F. L . iJ W � No 2 Offense �b'"� w , .. � ! No 3 Offense S'�'0rdinan� � ❑Speed 169.14(subd ): mph zone ❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) AC Taken—AC: Test type: ❑ Refused ❑ Breath ❑ Blood" ❑ Unne � ❑Hazardous Material (D0� ❑Unsafe Conditions �Scfad Zone ❑Endangering L'rfe& Property ❑Work Zone ❑Commeraal Veh. DOT# Identffication: ❑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 Drivers License must be shown at one of the Violations Bureau locations listed 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 carefull,,,and respond. i i i - `:�}�, � Officer(s)Name(s � Officer No(s) - .. � � � . ' � How lssued Person ❑Mailed � � - ; DEFENDANT ("' (.. _�__.`.. l 374667 _ . DATE¢�_ �` J � _ TERMS_ _ _. _ ` (o TO � r � (V w�� ' s IN ACCOUNT WITH r � , �� !-� 1 ci`'� (i lS hl( G o� 1 � ` � �� CURRENT OVER 30 DAYS OVER 60 DAYS TOTAL AMOUNT o,-„ ��adams•oceei z