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Cao ��f�/ED � �AN �� NOTICE OF CLAIM to the City of�S�a n�`Paul, Minnesota Minnesota State Statute 466.05 states tha��.eve�L E RW�o claims damages from any rrca�nicipaliry...shall cause to be presented to tke governing body of t/te municipality within 180 days after the alleged loss or injury is discovered a notice stnting 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 ��'�.�1 Middle Initial�Last Name l�iv C��mran� c�r Business 1'ame Are You an Insurance Company? Yes/N� If Yes,Claim Number? Street Address� �� (`;c:,�.�'� ��, City �`S�� '�Ci�,� State ��^�1 Zip Code � � Daytime Phone(`tr.�I )�-��Cell Phone(��o�i)�-�Evening Telephone( ) - Date of Accidentl Injury or Date Discovered ��- a� : �("�I� Time � ar'rj/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 far your damages.�,(�Ir �uc�S tav�c:� ,_ ., . � , � t u� `, r � i uP. �i. - �- C� � 2� ,S(..� � ��•;r- � e n C. i � �v wC1a , e _} c � � �� t .�;,�.�, �, — - � c � - .,. � � 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 ��ehicle was wrongfully towed and/or ticketed ❑ I was injured on City property O Other type of propeny damage–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 andJor 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 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 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? Ye � No Unknown (circle) Provide their names, addresses�nd telephone numbers: �1 e,YYI � � k5`{� :�u t'�, ��(� � � 5��1`� l to5�� .�� - l3`�� Were the police or law enforcement called? Ye� No Unknown (circle) t If yes, what department or agency? `V � - Case#or report# ' � Where did the accident or injury take place`? Provide street address,cross street. inrersection, name of park or facilit�. closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. �� ca�t c1- V�t4� ��C�z_ l0e�u.�sz..�� ..�cAS�,c: S� �- T1-..�,c� « • Please indicate the amount you are seeking in compensation or what you would like the City to do to resol�-e this claim to your satisfaction. � .� I�'1 - S�% ( -�t� CYu.�.�'�:,� � Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year at�`� Make � Uu Model License Plate Number olSg C�l� State��Color �t� Registered Owner �� .� ('_� Driver of Vehicle - Area Damaged t�',c; `I�rv�� f'_I�.ins, �� -ti;,.> c `v,r.,;,,� City Vehicle: Year Make Model � License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injury Claims—Alease complete this section �check box if this section dces not appl� How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning ro Seek Treatment(circle) When did you receive treatment? (pro��ide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes 10 When did you miss work? (provide date(s)) Name of your Employe�; _ _ _ _ Address Telephone B�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 �?C-• �� =�O) Print the Name of the Person who Completed this Form: I '�� Signature of Person Making the Claim: Revised February 2011 � � �1T�TIO�I State of Minnesota Ramsey District Court City of --' I Citation# I IIIIII(IIII IIIII IIIIi IIIII IIII)IIItI IIII)III�I IIIII Illll lllll llll llll 620900201639 620900201639 DL Number State ' ❑MN ❑CDL Name First Middle Last Address— Street, Apt# City State Zip DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity Vehicle License No. Plate Year State Make _ Type Model Color , �`, E Date of Offense Time,of Offense_ ❑AccidenUCrash � � � - -- . � �� ❑Property ❑Injury ❑Fatal ❑Pedestnan � Parking Meter Number Neighborhood Code ! � Housing/Building Code N � ; ❑Booked ��rk%Operate ❑Owner ❑Passenger ❑Driver O Offense Location ' 0 ._ N NO 1 OffenS@ Statute/qrdinance � z � � . 1`� '- � No 2 Offense Statute/Ordinance � , � No 3 Offense Statute/Ordinance ❑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 � ❑Hazardous Materiai (DOT) ❑Unsafe Conditions ❑School Zone ❑Endangering Life & Property ❑Work Zone ❑Commercial Veh. DOT# Identification: ❑DL ❑DVS Web ❑ Photo ID ❑Other See back of citation ior information on paying your fine. ' If dted for No Proof of insurarce or�lo Driver's License in Possession, Proof of insurance andlor Driver's Licerse must be shcwr,at cre of the Violations Bureau locations listed on the back of this � citation wifhir 21 �'ays rrom tne tlaie the citation is filed w;th the Gourt. Please read the back of this citation carefully and respond. Officer(s)Name(s) � Officer No(s) ";� �� CN#� � '" , ,�`'� Citing Dept ; ; _� � How Issued ❑In Person ❑Mailed Dteft at Scene ' DEFENDANT fn � 0 0 � m � � � _- � � � � � y c� O � � � �.< - m ce a m m � � � � � � v v w � (L� fn (/1 �p N C Q (p � C�D � � p� C N n N �- C7 Q" (D � � � � � � Q � O � (�n � .� O � � � � �' � n� C � � ` � � � � � '� p�j p � N N � � a � � � N � Q O � CD � � � � n N � D O Q � C7 � C�D -a C �N � � � 0 N �l'I CU �' Z � � � � � � (�D O A N � = I � cQ 'D �p � �. 0 � � -� � � � .' C � � O � � p �. 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