Karels _ /
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shaU cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and tlie amount of conapensation 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 !�,������� Middle Initial�Last Name f.(M ':�1� t'��/'�C I` �C�y
VC V CV
Companyo ur Business Name_.____ ____.___
_ _ __ -- _-------_ ----------------�A N 0 6
2014
Are You an Insurance Company? Yes/N�i If Yes, Claim Number?
Street Address .�5 � 1�� r $i �� S- �ITY CLERK
City ��.e%%►1 l�lN P ��('(�� State� Zip Code-����
Daytime Phone�)-r✓�s- 1�'c�JCell Phone r� )�1-�7 1 Evening Telephone�)�- 1��
Date of Accidend Injury or Date Discovered� . �o O 1 _ Time .C� ar /pm
Please state,in detail,what occurred(happened), and why you are submitting a claim.Please indicate why or how you .
feel the City of Saint Paul or its emplo ees.are involved andlor responsible for your dama es. Q�� �� D�I��LIC S
S�'r• . I� i � ' ` 1 w rni�k�l
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nr �;fi�` or�ni�q a�r ivr.Fo;,,,�d , p� irm � Fr.�, StYrss .oF� sR��a� �. Wh��l� YYt� 6ah W�s in t�h�
�lease chec the be�k(es)that most closely repre�Sent�he reason for complet�ng this�orm: h°��rt�,i i n (,rj}�'c'cLl
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow — -
❑ VIy vehicle was damaged by a pothole or condition of the street ❑ My vehicle was darriaged by a plow L�r�_ �fi��
1��ty ��ehicle was wrongfully towed and/or ticketed ❑ I was injured on City property 61(`, '�y(�$tyy��j�
❑ Other type of property damage—please specify
�Other type of injury—please specify � � �� �gr� � � (� � O��aO�'r •
t�� S ��? �:D-„ c..rkx�.r��ss�wner!1 D u�k�a �o��f r
In order to process your claim you nee to inclu e 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
$500.00;or the actual bills and/or receipts for the repairs
�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
andlor receipts for the repairs;detailed list of damaged itemsn_ ''"� �
� Injury claims: medical bills,receipts —� �GGI�i'rS 1�I"► ��1"Lt,� �GG�I�I.tS� QY1C� �OS� �fQ�W�.tnL
O Photographs are always welcome to document and support your c aim but will not be�eturned. ��� � �
Page 1 of 2—Please complete and return both pages of Claim Form
. �
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease complete this section
Were there witnesses to the incident? Yes N Unknown (circle) S
Provide their names, addresses nd telepho e numbers: �,V1�1d � s �� �� �
c �fn< - • I D o t rn.G
now w o i�uu� I�V�e. ��nt�c} 'r
Were the police or l�lw enforcement called? Yes �N Unknown (circle)
If yes, what department or agency?(�LC,r-}� �J Case#or report# 2 I �Z��'D CN i�
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
Please indicate the amount ou are seeking in com�pensation or what yo would like the Cit to do to re'solve is��3 !�
your satisfaction. � 13 50�1 ' ',i Q, 1 •
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�j mc W t1� owr C'h i 1 d 0:�t� �X 1� � s U,S fit� �fi'i�d e o u.r Ye.h�c-t t�. I l U.�, tv Gi
0:
Vet►icle Claims— lease com lefe this sectiun ❑chec box if this section does not a 1 n iG���
Your Vehicle: YearZi ��0 MakeNi'� Model r�r,��tf � �/
License Plate Number� �7C(rL i ., State IYf�_Color Red / C�1^c�i
Registered Owner � or G�
Driver of Vehicle �Y:c�rtui �/ KAtbre.r�rti�
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 box if this section does not a 1
How were ou injured? ` ' � � ���� �'✓� � �'�'
� t• ' 1 ' ►h r G-" �� �11 Son` ��ul �c�,i�i{�
What part(s)of your body were injure . � ..- 1�'� �-� •� �
l e, c ° ��v�. - ec_ e S sS �t
Have you sought me ical treatment? Yes � Planning 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 �
When did you miss work? (provide date(s))
\a...e of}our Employer: �
Address Telephone
�'Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this fornz,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �d�—�+�a (�J
Print the Name of the Person who Completed this Form: T���'��Y�P G�t�V��S
Signature of Person Making the Claim: `�`�uul��l�Q- ��
Revised February 2011 . , �
JI�S v� fi��1� �C�t � `FOY' I1'� U�d �eS
�nc���ea co�' � 1� P�
��� �- �� � � �
�ir,c�r,c.���l ��rr�p�,scLt�o� �r firn� -w ti I� this jvrm o�.t ,
pa�-�L -��5 , Crzlli►� �evc�i��ne Fc�Ssi�le tih �►i-i� c� � 5�, (�c��,� ,
fi�m� 1,o c��e�- -t►�Ics , stun� �n ►►mpe��-,r� line �dur�ny a sneu�
eme�y�� � ) a�d dr�ve firom St� Pc�.u,t �h�Id�r,s �t� Cot�e G�vc,
�1 �m ou.rtol �t b�c..i�. td Ch�ldr��,'� �,li b��ctU
}-p St� �C�u, p I� aC., D�
�He ���� S �rD r p d
Saint Paul Police Impound Lot, 830 Barge Channel R:�ad, Vehicle Release Form
Make: VOLKSWAGEN License#: 604GBZ CN: 13272990 Invoice#: 24140
Date/Time Released: 12/26/2013 11:54 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00 �
Paid by: CASH Admin Charge: $ 80.00 �lJ�-�
Released by: BONNIE Tax: (7.625%) $ 15.55
t,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge �will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature s�2000
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 11 NISSAN License#: 407EGL CN: 13272990 Invoice#: 24509
Date/Time Released: 12/26/2013 11:53 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00 f�
lJ��
Paid by: CASH Admin Charge: $ 80.00
Released by: BONNIE Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS, REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature si2000
i
� �� � -
; State of Minnesota Ramsey District Court
City of
i Citation# I IIIII�(IIII IIIII IIIII IIII)I�III IIIII IIIII IIIII IIIII II�II IIIII II�I III)
j s20900205625 620900205625
� DL Number State
i ❑MN ❑CDL
i Name
First Middle Last
� Address— Street, Apt#
i
� City State Zip
�
i DOB(mm/dd�'yyyy) Eyes Height Weight Sex Race Ethnicity
i
f Vehide License No. Plate Year State Make Type Model Color
; ,
;
Date of Offense Timeof-�ffense ; ❑AcadenUCrash
: ' =` `" t' ❑Property ❑Injury ❑Fatal ❑PedesVian �
Parking Meter Number Neighborhood Code ❑ Housing/Building Code N
�
j ❑Booked �'Park/Operate ❑Owner ❑Passenger ❑Driver O
�
; Offense Location Q
�
_.,„, N
� NO1 OffQRS2 Statute/Ordinance 0
i - , � . 1 r:"" ,.� . . . . �
� No 2 Offense sr�mt�ro�ama�� �
N
No 3 Offense sca���eioro��a�e
�
i
� ❑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 ❑ Urine
i ❑Hazardous Material (D0� ❑Unsafe Conditions ❑School Zone
! ❑Endangering Life & Property ❑Work Zone ❑Commercial Veh. DOT#
f
; Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other
See back of citatiorr for information an paying your fine.
4 If cited for No Proof of Insurance or No Oriver's License in Possession, Proof of lnsurance and/or
� Driver's License must be shown at one of the Violations Bureau locations listed on the back of this '
� citation wiihin 21 days from the date the citation is filed with the Court. ��
� Please read the back of this citation carefully and respond. '
i
'
i
i
�
Officer(s)Name(s)
Officer No(s). � CN#:' Citing Dept
How Issued ❑In Person ❑Mailed ❑Left at Scene
�
` E7EFEN�AN�
i
i ��������
' SWte of Minnesota Ramsey District Court
City of
',I Citation# I IIIIII IIIII IIIIIIIIII IIIIIIIIIIIIIIIIIIII(IIIIIIII)IIIIIIIIIIIIIIIIII
'i 62090020562fi 620900205626
�
DL Number State
� ❑MN �CDL
Name
First Middle Last
Address— Street, Apt#
i
' City State Zip
� DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity
i
; Vehicle License No. Plate Year State Make r Ty,pe Model Color
� � �,,�.; �. " �� � .
� Date of Offense Time of Offense ❑AcadentlCrash
` ..:. �' ,.� ❑Properry ❑Injury ❑Fatsl ❑Pedestrian �
! Parking Meter Number Neighborhood Code ❑ Housing/Building Code N
i �
❑Booked C4 Park/Operate ❑Owner ❑Passenger ❑Driver O
� Offense Location - � �
, ; N
i No 1 Offense scatmeiordina�ce 0
� V'1
i �
� NO 2 OffeflSB Statute/Ordinance �
,� �
iNo 3 Offense Statute/Ordinance
i
❑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 ❑ Urine
j ❑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 citetl 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 locaiions listed on the back of this
� citation within 21 tlays from the date the citaiion is filed with the Court.
� Please read the back of this citation carefuliy and respond.
�
�
�
i
� Officer(s)Nar�e(s)
Officer No(s). . CN#r '� - Citing Dept
How Issued ❑In Person ❑Mailed ❑Left at Scene
� DEFENDANT
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