The URL can be used to link to this page

Stierwald RECEIVE� - - ' JAN 0"7 2014 . . . / M. ,.� • ...v�� NOTICE �1��D�R�RM to the City �i��iinnesota Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipaliry within 180 days afYer the alleged loss or injury is discovered a notice stating the time,place,and circumstances 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 V�� Middle Initial �A .Last Name J�'e.�W�� Cornpanv or Business Name � Are You an Insurance Company? Yes/� If Yes,Claim Number? �f�'� , Street Address l�� S�� 1�V� City � P�tti� State M� Zip Code S��T Daytime Phone ( ) - Cell Phone( ��)�_��vening Telephone( ) - Date of Accident/Injury or ate Discovered U'eC• Z�pl 2,_��3 Time �:�S 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 andJor responsible for your damages. �n <<'1 j'��S�GS a��A��y— -7� �; Z w e w►e� .•� . ur I �1 :3 t �-�,.o t/el�c1e, 4nr��-t�i!�lo�cl ��lrx,�o�,cbe wr'Fwtss,e �two pb�w+s ci� t►-+w�l'swo /-4- 0 �/ . Z1+�0✓C� �/G�i c�GS J- ��1' ''Ip� � �'w ' „b. •�� u�✓ t� 3 '� � -}�,"�3" � �,,c� c P , 1 . 1 �° �91S wr � 39.� �'`� � i � d i s M�SxL ' c�h ��C�ls a� P�`^� "� w�-i�+ �s G l t`v�n -�ix'M- �"'�� 3�+er i � "k'"� P ease check the box(es�that most closely represent the reason for completing this form: � � �t� ��ehicle was damaged in an accident ❑My vehicle was damaged during a tow O �1}' �'ehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ' �� •° ^.d3��:�1--_.._._-- .--—.-- _ ___D I was i��d-aa�ity�roperty - Other type of property damag�;—please specify � ❑ Other type of injury—please specify In order to process your claim you 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 $500.00; or the actual bills andlor 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 e,stimates if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs; detailed list 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 n _ - -- -------�-------- -_--�-•---�---_-- _ :-�_ — - R 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 Unknown (circle) Prp_vide thei�names,addresses and telephone numbers: �.�� 2,.i ��',n..,,� ,a.r��r��c�G C �'� �Y1�1 S�an, So � Sr'►o�✓A u/ r� fec.ti,.LS 9�.nv YMr iE� ��P _ - i�.4..�1� f Were the police or law enforcement called? Yes No Unknown (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 of park or facility, closest landmark, etc. Please be as detailed as pos ible. If necessary, attach a diagram. On�'�.,P �/P�� gs�e o-� Cht�.hwa�'�, �} be�✓ee,, t.a.,�-�I •f- �o�'la,��.� wh;f1. �s -�lite `'N;4�low �x.[e s;�`' , Please indicate the amount you are seeking in ompensation or what you would like the City to do to re'solve this claim to your satisfaction. ; ` IA/ �c5 � " m� �ra�►5� �3. o O L '� Oo , Ve}ucle Claims- lease com lete this section ❑ check box if this section does not a 1 ' �.L. Your Vehicle: Year /9 97 Make Chh�� Model � ✓� � License Plate Number�32 LN� State�[�Color �,Ohrv�1. Registered Owner .-'C'nr.,�-�ki„_ �j��f� Driver of Vehicle �011f' Area Damaged zn� �+Vehicle: Year 1,00o Make /�T�Z G� Model f 8 '� License Plate Number State Color (j,r�r/1 Driver of Vehicle(City mployee's Name) �1,4. Area Damaged ,�//� Iniurv Claims-please complete this section �check box if this section does not ap� 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)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) . _:�_. __,i�Fame o�'ytw-i�rn-�er° ��__�. ._ �._._,_,��...._ ��- _____. �— . 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 processed. Submitting a false claim can result in prosecution. Date form was completed 1� v`�n� �� Print the Name of the Person who Completed this Form: ��n�^'� w' ��RWf�L� Signature of Person Making the Claim: Rc�:�Fe'_�r.�ar� 2011 � � �� - P,�'� ,�� .�.� � ��' �� l�r�a� � ' � �� ',� ��-' n►�",�, ��C;,,�' �. ,,� � ��i�/� GPS, tiec��.�- � �� . � ��'��.� �� ' �.�� .�'� �� , ,�� .�� .�� -��- ,�� ,�°�-� �.�.� �- ��v, Go Py o� C f�� ' �e�� ST PAUL 1PPOUND LOT 83t7 BFiRGE CFK�IEI. RU ► SAINT PAUL, 1W. 551b7-2450 651-266-5642 plerchant ID: fS0063SN149 Term ID: Q161734�H[#�5384314405 $ale zzzzzzzzazzz1618 �' VISR Entry�eth�i: S�i�ed �' �J 4� lotal: f 439,��----�' U��L�.�S 12�26�1� 13'�'� ¢,� 2� a�a Inu �: R�r Cade: 3162$'1 �{� ��J �vrud: Qr,line C,�stanrr CoPr . f!!pt�i 'r'fH!! �aint Paui Police�impound Lot, 830 Barge Channel Road, Vehicie Release Form , Make: CHEVROLET License#: 032LNH CN: 13272990 Invoice#: 24224 Date/Time Released: 12/26l2013 13,35 Tow Charge: $ 123.95 Released to: TOTO Storage Charge: $ 0.00 �01it1 V11 Paid by: CREDIT CARD Admin Charge: $ 80.00 Released by: LEE 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 I.OT Signature s�2000 Saint Paul F�olice�Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: MAZDA License#:XYD069 CN: 13272990 Invoice#: 24223 Date/Time Released: 12/26/2013 13:36 Tow Charge: $ 123.95 Released to: TOTO Storage Charge: $ 0.00 �Q W �� Paid by: CREDIT CARD Admin Charge: $ 80.00 I Released by: LEE 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 1 will report damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.5� 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 5/2000 Signature � ' . ; . i �` �' State of Mitu�sp� � + City of�-_ , , ��mseY District Court ,>. .,_.: i Citation# � � ; �� 2 �� 090 �� 02 �� 013 �� 3 620900201303 , DL Number State ' r,s��►�oae ta� ❑� C� Address–Street, qpt# � C� � Siate d06(mMd Z�p �YYYY) Eyes Hei ht ? 9 Weight Sex Race Ethnicily � Vehicle License No. Piate Year State Make , ry� f Qate of Offense �' �� Color � >�. Time o� ense . ❑Aa�deM/Crash� . , Parking Meter Number Nei hborh �P�r ❑�`�„y ❑Fafal ❑P�S� 9 °°d �°de �HousinglBuilding Code C� ❑Booked Li P�7p�rate Q ❑Owner O Passenger ❑Driver � Offense Location � . No 1 Offense° � `f . � .,- . _ e ,; � �� _ Statutdprdmar� ; � No 2 Offense � � � � � � �� W No 3 Offense O s�nn� GJ ❑Speed 169.14(subd________ � F ❑No Seat Belt Use 169.686.1(a), mph zone ACTaken–qC: �Mo Proof of Insurance 1gg,791(2) � Test type: ❑ Refused ❑ &eath ❑Hazardous Material(D0� p Unsafe Condftions � B�0°d � Urine f �Endangering Life& Pr �5��Zone � °Perh` ��Nork Zone ❑Commerciai Veh. DOT#___ � fdentification: p p� ❑DVS Web ❑Photo ID ❑p�er � . 1 � � � _ _ _ � ; ,., ; � R�POEtF t�EG11Y��8�� ' � ��`� �'�� A ` a .�.�.�`, ��_ uwe�ca�. : i � �►�S?Name(s) � Officer No(s). : _.. ' ` '' CIV# • _. � , � How Issued ? O In Person ' , � = ,= Cding pept• , : ; ��., _ �� -"_�"- , t � ClLett at Soeoe # i __— _ � , � -, , � �d�� Ramsey District Court d�r d Citation# � ' ' (I�I II�� q I ��I��II��I�� ' 6209QQ2Q�3Q4 620900201304 u � � a� �� ❑MN ❑CDL � Name Frst Middle Last Address- Street, Apt# � City State Zip DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity Ve icie License No. Plate Y,ear State Make Type A+�del Color � �� .c� � r,�'�' MG�Zd �c� t��. ' � _Date of Offense Time of Offense OAcadentlCrash � ` : l� � ❑Property ❑Injwy ❑Fafal ❑Pedeshian , Parking Meter Number Neighborhood Code ❑ HousingBuilding Code N ; � � # ❑Booked ;fl Park/Operate ❑Owner ❑Passenger ❑Driver O i Offense Lflcatian Q � v�5 C�-,� SvV.�;-��''S �7 w - L ,�u�� t c�,,n E�E'c�'l l�m ; No 1 Otfense �� 0 � � ..�► _ _ �., , , �. .; _ _: ; ,: - trkl No 2 Offense ��o�e � � � � E No 3 Offense s��o�� i � � ❑Speed 169.14(subd ): mph zone 0 No Seat BeEt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) AC Taken-AC: Test type: ❑ Refused ❑ Breath ❑ Blood ❑ Urine ❑Hazardous Matenal (DO'� ❑Unsafe Conditions ❑School Zone ❑Endangering Life 8� Property ❑Wo�k Zone ❑Commercial Veh. DOT# Ident�cation: ❑DL ❑DVS Web ❑Photo ID ❑Other _ j _ � RLROR�DE�Et"�11��IE�R�BY t�0(t�i t�N�t7'�##�lY, = � t�re�n�� (�� 'S � f st,#�► - ` ��[,tlGnwus ; , � . Officer(s)Name(s) � � Office�No(s). , .>, Cp!#�� Citing Dept �_ , � � Howlssued �` ❑InPerson OMailed.�Y ''CJLeftatScene. � _ 1 i