Aubin NOTIC� OF CLAIM TORM to the City of Saint Paul, Minnesota
Mi�rire.suta Stute Stc�ltrte 466.05 s(ntes ihnt " ...e��ery persun...whn clnirns dunta�e.c/i�nm aiiv�nuniciptiliry....shall cau.ce in he p��e.�•ented!o d�e
�o��ernrrrg bocly qjdre nuu�icipa(ity H�rdtu� I�SO du��s nf(er Ihe rt/legecl lo.�s or rnjwy is drscovered n rrotic•e statiirg dre tin�e,place,ui�d
rire�unrstu�fces theren(,and the nmount o/cnmpensntinn or other relie/�denrnnded."
Please complete this f'orm in its entirety by clearly typin�;or printin�;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 answcrs,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowled�;ement once your f'orm is received. The process can take up to ten weeks or longer dependin�on the
nature oF your daim. 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 � I C-I 1��el Middle Initial ��Last Name /'f Vt Di Vl [a C�E�
.
Company or Business Name 14
Are You an Insurance ComPany? Yes No If Yes, Claim Number?
Street Address
�3 �y I��lo %«►'I So�,c,�-f� RK
City �D}�'�� 1'C U e-- State_� �,� Zip Code S 0
Daytime Phone ( �� )y�-�7/7.S' Cell Phone ( )� - Evening Telephone ( .S� )�5��° - 71
Date of Accident/ Injury or Date Discovered �Z-�8 �013 Time /d= W am/�
Ple�ise state, in det�iil, what occurred (happened), and why you are submitting a claim. Please indicate why or how you
feel the Citv �f Saint Paul or its e nployees are involved and/or responsible for your dama es. � In1A.S t�a�k� /e�W��
� �
pn wcl,.H+ 4�c,�c `�� � �r� �e .S b��� e�u:ee� �' � �n�, �-- �'. W he� �' o m i- i I,�a� �r�e .
� t�;c<s �e�6 S-f��,�le i r r o m i�u�� ' ,! . —' wc{� �-tc f �t c��� c�rn �en w cla�l,
���,,� ���t u o� � ,hi� e� el � ��rm _ 5 �-e�. wcs ,� � h��f ev�► � ne ve•1r�1`
' 4,e , J- i Same �eSe-c+rth o�� 'n�}ern�� a I.uheu-�'tie� Imanac r o , w.1 .P���,l
�, �Z-� -?��3 n w �l . la-17�20� . ', �� vul �om /�.?0�3 / -If.2v��
o c►�,' e . �t er�o� � snow��fe la� � o � e er e,�c '. .ST Pc.� here �e n'�
G�ir Shou ncr� ha� b�.e� �ficK��i�e o� -}c�we �
Please check the box(es) that ►nost 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 �i plow
�My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ 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
$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
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��our claim.
All Claims—please comn�ete this section
Were there witnesses to the incident'? Yes � L'nkno�n (circle)
Provide their names, addresses and telephone numbers: /1,/�
Were the police or law enforcement called'' Yes tio l:nknown (circlel
If yes, what department or agency? Case #or report #
Where did the accident or injury take place'? Provide street address,cross street, intersection, name uf park or facilit�.
closest landmark, etc. Please be as detailed as possible. If necessar�, attach a diagram. �?//`t
Please indicate the am unt ou are seeking in compensation or,what you would lik the Cit}� to do to resolve this rlaim
to yp ur satisf•ction. -� c� TOW Ct �� e i��' ��'1 � G /7�7 '
Cr��pe�. ��y /�fk� f�'a�r ci'-1y Q�c %� �c� ,19//�e� fuLlic i�,b�kf I,�e�f�� u;e-� �ri�_
Vehicle Claims—please complete this section O check b�x if this secticm �Jc�es not a�ly
Your Vehicle: Year ��(I Make Ch sla� Mociel �dv
License Plate Number � 7 State�/ A�.',Color 131lic kberry PC�i�1 ( �rk ��ue�
Registered Owner Cher l �.c�i nl i c hae( Nua;
Driver of Vehicle � hc�e 1 � ;'t
Area Damaged
City Vehicle: Year Make Model
License Plate Number Statc Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injurv Claims—please complete this section �check box if this tiertion doe� not a�lv
How were you injured?
What part(s) of your body were injured?
Have you sought medical treahnent? Yes No Plsnning tu Seek Treatmen[ (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 tio
When did you miss work? i pru�i�ie datei,r�
Na�ne of your Employer:
Address Telephcme ____
❑ Check here if you are attaching more pages to this daim form. \umber of�dditional p�k�s ___ _.
By signing tltis form,you are stating tlrat all informatioii you /iave pro►�ided is trtie and correc�to tlre bes[
of your knowledge. Unsigned forms will irot be processed.
Submitting a false claim can resttlt in prosecution. Date form was completed /' �C" �/�/
Print the Name of the Persun who Completed this Form: � � �h�e I /�u�;n
Si�;nature of'Person Making the Claim: G��'��+� ���,� -
Revised February 201 I
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CITATION
State of Minnesota Ramsey District Court
Cityr of
Citation# ` I III�I�N���I IIIII�I�I IIIII III��IIII�IIII 1I�I1 UII)IIII llll
620900172335 s20900172335
DL Number State
❑MN ❑CDL
Name
Frst 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. Nbdel Color
, , � : . - ,-
�� � ' � �
Date.of Offense Tir�e of Offer�se ❑AaidentlCrash'
; .:: _. � ❑Property ❑Injury ❑Fatal ❑PedesMan
Parking Meter Number Neighborhood Code ❑ HousinglBuilding Code N
�
❑Booked Q�Park/Operate ❑Owner ❑Passenger ❑Driver O
Offense Location �... , � ' �
� � � ; � �;: � d,'.' ',� � � �
_ ' ` ;_ - �
No 1 Offense sca�rte�ordina�,�e y
, _ ;;. � �>� ' ' i
N
i No 2 Offense s�a��°`d'"ar�e W
C�1
No 3 Offense s�nrt�om�r�
❑Speed 169.14(subd ): mph zone
❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169J91(2)
AC Taken—AC: Test type: ❑ Refused ❑ Breath ❑ Blood ❑ Unne
�Hazardous Material (D0� ❑Unsafe Conditions ❑School Zone
❑Endangering Life& Property ❑Work Zone ❑Commercial Veh. DOT#
I 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 andlor
Driver's 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 carefully and respond.
Officer(s)Name(s)
Office�No(s). y CN#� . Citing Dept
,, ..
Houv�fissued ❑In Person ❑Wiailed O Left at Scene
DEFENDANT •, �' `'
.,_.�