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Yang, Tommy NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota 1f:��esota State Stature�65.05,states th.at"...every person...whv cl�iinu damages from any municipality...shnll cause to be presented tu the :o.err.irtg bod��of the munrcrpality withir.180 days after the alleged loss or injury•is disc��vered a notice statir.g the tirr�e,place,and cireu�:��s�ances thereof,und the amount cf compensn;run or o;her��elief d�manded.° Please complete this form in i�s entirety by clearly typing or printi�g}•uur answer:a Fach questiQn. If mr re space is needed,attach additional st�eets. Please note that you will not be contacted by teleghune t�clarify answers,so�:mvide as much information as necessary to explain your claim,and the amount of compensation being requested. Si'ou 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 botli 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, NIN 55102 Fint�ame W� `�� Middle Initial__Last Name �'� ��v�� ,i;IIlPau)� JT bU5ltic��aITK � ti� --- �? ��1� J � Are You an Insurar.�e Company? Yes�e' If Yes,Claim\umber? �,ER� Scrc�c.�ddress ,2-ZS �.'J�:S r./��n-5 )rt_r � �" �-�S Cit� ��:.�; � Statt�� Zip Code ��3c' Daytime Phone (_) - Cell Phone(�)�'�- �IG� Evening Telephone( ) - Date of AccidenU Injury or Date Discovered r2' ��. �� Time ? am/pm Please state,in detail,w�hat 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 for your damages. IM � �a,i .� �1t-n. (�rti�" ��?a,r G_ C'l�? J''� �1 G�n G�r.� � �1 L� � � �1 c - /'�-• �C G.��L � � C� r ''t � W c^ ;�� 2 a � � !� q D�:, ,��c,.� ,-�r-, �,�� m — �t a n-� . 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 dama�ed b�� a pothole or condition of'the street ❑ My vehicle was damaged by a plow I�T��vPhirle wa� �.;�ro�g±�l:} to«ed and/or ticketed ❑ I was in;ured en Ci�}�pra�ert� ❑ Other type of propeRy damage—please specify ❑ Other type of injur� —please specify In order to process your claim vou need to include copies of all auulicable documents. For the c:ai:r� c��rs li�ted below,please be sure to include the documents indicated or it will delay the handling of ��our claim_ Dczurrxnts WILL NOT be returned and become the property of the City. You are encouraged to keep a cop�� for yourseli before submitting your claim form. O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds S500.00;or the actual bills and/or receipts for the repairs �Towing claims: legible copies of any ticket i:�sued and a copy of the impound lot,receipt O Other property damage claims: two repair estimates if the damage e�.ceeds$500.00;or the actual bills andlor receipts for the repairs;detailed list of d�unaged 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. :�11 Claims—nlease complete this section � «'ere there wimesses to the incident? Yes �I'�� Unknown (circle) Pro�ide their names, addresses and telephone numbers:_ _ ��'ere the police or law enforcement called? Yes No Unkno�m (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,possible. If necessary,attach a diagram. � �� T �� ,�, � i-�a :1 -r�� .z � a. �-�' � zzsr c,✓�sf-.�, �,�s F�.� sr Please indicate the amount�ou are seeking in compensatiion or what you would like the City to do to re'solve this claim to your satisfaction. �" 2 j % - S�� Vehicle Claims— lease com lete this section ❑check box if this section does not applv Your Vehicle: Year �� Make � !�' � vlodel��,,_n.� r v License Plate Vumber � � � Uf5' State�Colo�� Reoistered Owner �-�C �l�3--N u Dri�er of Vehicle 70�+ M �' y�9 N� .�rea Damaged ,?L/r4 Cit��'etucle: �'ear Make� �1ode1 License Plate Number State Color Dri��er of Vehicle(City Employee's Na�ne) Area Damaged Iniurv Claims—ulease complete this section ` check box if this section does not applv 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 «�ork? (provide date(s)) \�r.:e . ;ou:Fs:.l,:o}e: _ . 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 Print the\ame of the Person who Completed this Form: �� r'" ��' / � ''" v Signature of Person Making the Claim: � ` -.� Revised February 2011 51 PP� Lik'UUNu LOT � //� �3Fi �;riRG[ CI A�vt7EL RD �✓ SN]NT PAUI i1N 5i1F1i-245U E51 266 �642 � � � � 0 Q � � — — � � � � � � (Q � � A> � � �. A) � 3 (D a1 (D A� Merchant [D: kt�ld63d01a4 7 � n' � �. � �`G = (D (p Q (D ("p �T. �• Terw IG: k�617341J11F16$FiU6.ii3k1144�3E � • � � n C N Sv � (D � � o � � o� � < m Q � `` � � � Sale � � Q -� � o � s�� `� m o � o c zzzzzzzzzzzz089Z � � o o. o �� m � o o � � o o V�Sp Entrv Metnod: S�iped � � � -` � � m � Q- D � � r�i, D — o Q � o.< o Q. � � ? c-� m m ci Rmount; � 219,50 1 �D m m o � � " < � a m � D iaz: � 0,�0 � -a su � sv � �, m � r1v � � a 3. � � � o � N � roc31, _�---_-_ -zi9�5� � I � � � � �' � � o � 12i26i13 15,06,33 z .. m < � � i �� , �� Q w � � Im a; 0�026 �ppr Code: 856536 � � �' " " �' � � RPPrvd: Online c° o � mo � � � r'' O -n � '... o � w < ° �n � � � Q- � � y � j. � (�J Customer Coav D � � �� 3 � n W THFINK YOU! -�G C� o � 3 (�D �- � � � � Z 3 � n � N C cQ � Q. _ � O n W � � � �' =`• � O N O K N Q- � �' O A� � f� � -+ � � z � � � � � i � D ° w �7 � � o m � X a � o � � a� < 3 ° � Q 00 � n � ° � �' � C� o � � ¢' (� � � cD � J � � .. � A� S (Q � W � o cQ � � � m �, � � � m r .. .. � m � c � � � � � � � � � � z N O � 1 � O N 0 (�p tJ� O � O O CJ� � O � C�J� � p _ � � m O � w _ o 0 � N O O O rt. ; � i CITAT�ON � Ramsey District Court � State of Minnesota � City of � IIIIIIIIIIIIIII IIIIIIIIIIIII� ' tion# IIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIII Cita IIIIII 02�4702 620900204702 � 62090 State � DL Number ❑MN ❑CDL � Name Frst Middle Last Address- Street, Apt# State Z�P � �`� Race Ethnicity ;; ppg�rnm ddyyyyl Eyes Height Weight Sex Plate Year State Make Type Model Color Vehide License No. 3 : ' 7ime of.Offense F ❑ACCId@f1VCf8Sh �Fa�� ❑pedestnan � � Date of Offense : ❑Properry ❑Injury N � Parking Meter Number Neighborhood Code ❑HousinglBuilding Code O # ❑Driver � � erate ❑Owner ❑Passenger � f ❑Booked =Q��P � Offense Location � �� StatutelOrdinance � � � � No 1 Offense O � StatutelOrdina�ce No 2 Offense N � StatutelOrdinance t No 3 Offense � mph�zone � ❑Speed 169.14(subd_—)��— ❑No Proof of Insurance 169791(2) r'No Seat Belt Use 169.686.1(a) Breath ❑ Biood ❑ Urine � Test type: ❑ Refused ❑ � G��.a -p� Unsafe Conditions ❑Schooi Zone ❑E�� 6 p��Y ❑Work Zone ❑Commeraal Veh. DOT#� i Identification. —� ❑DVS Web ❑Photo ID �Other � See back of citation for information on paying your fine. if cited for NoeP�°ust benshown at one�of therViolatonseBureauslocation sl�ted onntheaback of�this Driver's Licens citation within 21 days from the date the citation is filed with the Cou . Please read the back of this citation carefuliy and respond. Officer(s)Name(s) Citing Dept ° �� CN#_ � � Officer No(s). ❑Left at Scene How Issued ❑In Person ❑Mailed DEFENDANT