Ladron-de-Guevara NOTICE OF CLAIM FORIVI, to the City of Saint Paul, Minnesota
Miri�resntu S�ute Slutute 466.05 stc�tes thnt "...every person...w/�o clniats�lan�nges From any merniciprrli_ty...shnl!enu.se to he p�-esentecf to�he
governing budy of tfre nurnicipnlity witlti�a 180 dc�y.r after tlte al(eged loss or injs�ry i.r discovered a notice stating t/�e time,pluce,crnd
circumstartces thereof,and die antount nf contpens�tion or other relief demnnderl."
Please complete this form in its entirety by clearly typing or printinfi 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 DOCUM�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name
M�(� Middle Initial�Last Name ��I rO� " �� `—` ��'�-l-r�.
Company or Business Name t� �`
Are You an Insurance Company? Yes No If Yes, Claim Number? .��IV � ., .._4
Street Address � / 7 ��'� �j� �" � �� r '' E " ' • / � �
City �a-I �1� ��� ' State � �� Zip Code � �`�`K
�� � / �id - 76 2T
Daytime Phone ( ��,�' )� ���ell Phone ( ) - Evening Telephone�v�)
% /
Date of Accident/lnjury or Date Discovered � 2 ` 2 � - � d �3 Time ! > �D am/�
Please state, in detail, what occurred (happened),and why you are submitting a claim. Please indicate why or how you
feel t e City of Saint Paul or its employees are involved and/or responsible far your damages.
► �( .� c�.,Y' �.� 't.Z � D c� 1 N Q�
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��i �o� Ca'�n e ew� � �s rs �u �,v��- Iv�`I n�oYt�`Cr►� y t t�Co e %`s����1.a�
`�'`Pl ase check the box(es) that most closely represent the r �.o or compleh g�this f rm:
� ❑ My vehicle was damaged in an accident ❑ My vehicle was damage d during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
�l 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 you need to include copies of all annlicable 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 returne�i 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
O 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 pabes 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)
Provide their na►nes, addresses and telephone numbers:
Were the police or law enforcement called? Yes o~ Unknown (circle)
If yes, whut department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, interse ion, �q ime of p� -k facil' y,
cl sest lar�dmar� t Pleas be as etailed as possible. If necessary, attach a diagram. �Y�d C.(,�q?�
��= ss frc �`��� M � 5'S c� �
Ple�ise indicate the amoimt ou are seel:i g in compensatio��} r wh t ou would like th City to do to resol e this clai
to your s�tisfaction.� � Y1/L e c��'V �}� �Z O �I- ' (,(�'
/N c� , � M � 1 _ t� � vr�
,,��� � �t�"� o�..Z��.a,� n o °`��re � !�a.�,��. � �h�`.� "
Vehi e Claims- lease com lete th�s se o ❑ check box if this section does not a 1
Your Vehicle: Year C_� Make � `` Model � eJe.�; d rlo�.
License Plate Number State��Color •,
Registered Owner � �o- c� ' '-U i: �q p�,�a
Driver of Vehicle��,� ` ar�
Area Damaged (�o v�� .
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In_iurv Claims- please complete this section �check box if Chis section doe� not ap�lv
How were you injured?
What part(s) of your body were injured?
Have you sought medical treatment? Yes o 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))
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,yoi� are stating tliat ull information yoic have provided is true and correct to tlze best
of yoz�r knowledge. Unsigned forms will not be processed.
Sccbmittiizg a false claim can result in prosecrction. Date f'orm was completed l — 1(0 ° �0��
� �
Print the Name of the Person whu Completed th�s F 1'�C4. �i< .l.�C1�fGt�('cC-
Signature of'Person Making the Claim: -�'
Revised February 201 I
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MINNESOTA MOTOR VEHICLE REGISTRATION CARD RECORDED OWNER(S)RECORD OF SALE
PLATE TITLE PLATE !`4'
� PLATES ��1I�V �7 J TAX .... .-..NUMBER BAS�S 3 V L Z i� TITL'E ER v W� � 7� �
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� EXPIRE �,y 5 �F
MAKE �1.7�7�1` �y �� MODEL YEAR TYPE `3���} NUMBER �i 15�fl.�21�t
V.I.N. �g p�r 9j ICKER V.I.N. .,� y y p �., 'C
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�:":��� � ��i.L�TJ►7�irl����`>�T XY�Z71�� TOTALFEESPAID� � �
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, (S) C�Ty STATE ZIP CODE �
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VEHICLE IDENTIFICATION NUMBER ODOMETEFi MAKE YEAR TYPE �+
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TITLE NUMBER DATE ISSUED . NEW OR USED IF NEW,DATE OF FIRST SAIE FOR CENTRAL OFFICE USE ONLY `�
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lst��lITIOtJi�L LI �NS (i _
ASSIGNMENT BY SELLER(TRANSFEROR)
FECERA::.NC MIMJESO �:.V:nECUinE THAT'/vU STHTC THc b1iLEAue IN COrvNEC'fWN WITH'rnE TRANSFER OF OWNERSHIP.MINNESOTA LAW REQUIFES THAT YOU
MAKE DISCLOSURES ABOUT POLLUTION CONTROL E�UIPMENT AND DAMAGE TO THE VEHICLE.FAILUPE TO COMPLETE OR PROVIDING A FALSE STATEMENT MAY RESULT
IN FINES AND/OR IMPRISONMENT.SOME EXEMPTIONS MAY APPLY.
ODOMETER DISCLOSURE STATEMENT,I(WE)STATE THAT THE ODOMETER NOW DAMAGE DISCLOSURE STATEMENT.TO THE BEST OF MY KNOWLEDGE THIS �
� READS (NO TENTHS)MILES AND TO THE BEST VEHICLE ❑ HAS ❑ HAS NOT(CHECK ONE)SUSTAINED DAMAGE IN
OF MY KNOWLEDGE THAT IT REFLECTS THE ACTUAL MILEAGE OF THE VEHICLE EXCESS OF 70%ACTUAL CASH VALUE.
DESCRIBED HEREIN UNLESS ONE OF THE FOLLOWING STATEMENTS IS CHECKED. .-���
POLLUTION SYSTEM DISCLOSURE STATEMENT.TO THE BEST OF MY KNOWLEDGE
� � (1) I HEREBY CERTIFY TO THE BES7 OF MY KNOWLEDGE THE ODOAAETER THE POLLUTION CONTROL SYSTEM ON THIS VEHICLE INCLUDING THE RESTRICTED `�
� READING REFLECTS THE AMOUNT OF MILEAGE IN EXCESS OF ITS
MECHANICAL LIMITS. � GASOLINE PIPE ❑� HAS ❑ HAS NOT(CHECK ONE)BEEN REMOVED, .�'!���
� (2) I HEREBY CERTIFY THAT THE ODOMETER READING IS NOT THE ACTUAL ALTERED OR RENDERED INOPERATIVE.
MILEAGE.
I �WARNING-0DOMETER DISCREPANCY IF BOX(1)OR(2)IS CHECKED, ASSIGNMENT. I (WE)CERTIFY THAT THIS VEHICLE IS FREE FROM ALL SECURITY `
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�a� INTERESTS,WARRANT TITLE AND ASSIGN THE VEHICLE AND REGISTRATION PAID TO: �
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���MARIA DIVINA LAD(�N,OE�GUE'�/PiRA
777 HAMLINE AV�-W AP'T 12�1�_,
ST PAUL,MN 55�04 ""`' - f
DatedBirth��-$j-�� �
Sex Eyes -^-CTas��'+ :;� '
F BRN �;� ��
Height Weight ' •`
� 5-2 176 ���.'�� �
issuEO09-2013 `''.'.Fx�i�[S"D1-31-2016
,f�H468025215618 ��� ;
f ��� �I �
; State of Minnesota Ramsey District Court i
, City of �
I(IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII)IIII IIII '
Citation#
i
620900172138 620900172138
;
' DL Number State !
_ ❑MN ❑CDL
Name �
First Middle Last
Address— Street, Apt#
City State Zip �
' i
— �
DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity i
Vehicle License No_ Plate Year State Make yTyp�, , Model Color
r
.;� ;. � � . ;� , . - . . � '
. . . . ea'�.aaC'1 ..
Date of Offense Time of Offense ❑AccidenUCrash
_ � �� ' ❑Property ❑Injury ❑Fatal ❑Pedestrian �
Parking Meter Number Neighborhood Code ❑ Housing/Building Code N
' 0
❑Booked �Park/Operate ❑Owner ❑Passenger ❑Driver _ O ;
Offense Location ', Q
j � I
�- No 1 OffenSe Statute/Ordinance �
N
. �
NO 2 Off2I1SE 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: ❑ Refusetl ❑ Breath ❑ Blood ❑ Urine
❑Hazartlous Material (DOT) ❑Unsafe Conditions ❑School Zone
❑Endangering Life & Property ❑Work Zone ❑Commercial Veh. DOT#
Itlentification: ❑DL ❑DVS Web ❑ Photo ID ❑Other
See back of citation for information on paying your fine.
If citetl for No Proof o1 Insurance or No Driver's License in Possession, Proof of Insurance and/or
Driver's Lieense must be shown a't one of the Violations Bureau �ocations 6sted on the back of;his �
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) i
Officer No(s). CN# Citing Dept
-�
How Issuetl ❑In Person ❑Mailed �Left at Scene
DEFENDANT
. •- - . , :+ER��s� . .�# -� ,•�^c�,hc��!ms��n#n�ay,or to pay
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a I,i:t� >�.�1�i��� � �*.F{ f P 'S�.5EC4�ii��ild �
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- �ri,�..,, .': ��rB�;U �.OGaFIC?F�
;ub;�rliai�Court La�d Enforceinent Cenier
'aul��urt ,Z� C�ove Street
,g 0�i;�n"���e ?ear 1`�anua
, ^� I;F��oy� �iv� r;r� :.0 �,i_ Paul, MN 551Ci
�., r�tui, i��N 5310� qn�E�la��i���ou, MN �'03 �
�tflC� F'll,a�.,,- t�.i.n '-�a"•_:r���!1 ��`J' �.�Oli cj .1�11 t C��Cill-'�i,) HO�I��yS�
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uc,,:c.a ;i��t �ulanc.es. aite� �,C�,:��s ;`rom .�ic date���h,.,4it_�L�n �filea wiih �he Coui1 �,�� ,�idi?io!�<A!delinquent
fee>»u be added io ail unpald fii�e amounYs.
,HU'�.'.i011d� �u118ttIC5(fia)�If1CiU(IC.1) 'EiZ�7e1�1D Ire� �rE�dfii?lelll OT FU�D�IC SiifBiV(Of GiIVNI-�S iICe115E SiIS(1E1510i1,
2) refe�ral to a coilectlons agency.andlor 3;arres�warrant issued.
;;[he o�fense is a pelty misden;ear,cr,failure!o apa=����:wiil be consiclered a plea nf gu+ity and waiver of the right to
ii'�al ui�les��-'�e-a�lure tc�;ppear is due to circumstancc s bayond the person's controi(M�.S.169.91)and(M.S.609.4911—
Appeal
Te p;aad nct guilty, o;to plead guiity and ofier a�?axpianztion,take ihe following steps:
11 ;fier 10 business days, ca�i 651-266-9202 to cunfimi that the citation has been filed with the Court,and
2) raquest a i�ear!ng officer appointment.You must have a ohoto ID vvith you when meeting with a Hearin�
Officer.
-----------
I untlerstand that by payina this#ane I am enferira a plea oi guilty to this offense(s)and voluntarily waive ihe
following rights to:
a. a trial to the court, if offense is a peity misdemeanor,
b. a trial to the court or to a jury of 6 persons,if the offense is a misdemeanor,
c. representation by counsel,if the offense is a misdemeanor,
d. a presumption of innocence until proven guilry beyond a reasonable doubt,
e. confront and cross-examine all witnesses against me,and
f. either remain silent or to testify in my own behalf.
I also understand that if this offense is a petry mistlemeanor,the maximum possible sentence is$300.00;
if this offense is a misdemeanor,the maximum possible sentence is a$1,000.00 fine and/or 90 days imprisonment.
yt rRUi �nrounu �o�
83tf BARGE CHaIJN'tL RD
SAINT PAUL., MN. ���F�' �'�`'�
661 266`..�f;42
Mer�Y�a��t lt�: :;L+U633U144
l�ara� 1D: N617�i4lt0�306(t1�63'�5�14a1�6
Sale
xXZZZZZZxzzX?6�6
`�15p Ei7tr'� Method, 5�iped
Rmount. � 219.5�
iaz: � �'��
_
_.
Total: � 219.5�
12/26/13 18;21:23
Inu i�: 4���76� Rppr Codr; 9997N2
Apar°�c: Online
c,�5t�,�»r; c.�N�
TNANH YOU1
Your New Benefit Amount �ZBZ�
BENEFICIARY'S NAME: MARIA D LADRON DE GUEVARA
Your Social Security benefits will increase by 1.5 percent in 2014 because of a rise in the cost of
living. You can use this letter when you need proof of your benefit amount to receive food,
rent,or energy assistance; bank loans; or for other business. Keep this letter with your other
important financial documents.
How Much Will I Get And When?
•Your monthly amount (before deductions) is $773.90_
• The amount we deduct for Medicare medical insurance is $104.90.
(If you did not have Medicare as of Nov 14, 2013,
or if someone else pays your premium, we show $0.00.)
• The amount we deduct for your Medicare prescription drug plan is $0.00.
(If you did not elect withholding as of Nov. 1, 2013, we show $0.00.)
• The amount we deduct for voluntary federal tax withholding is $p,pp_
(If you did not elect voluntary tax withholding as of
Nov 14, 2013, we show $0.00.)
•After we take any other deductions, you will receive $669.00
on Jan. 22, 2014.
If you disagree with any of these amounts, you must write to us within 60 days from the date
you receive this letter. We would be happy to review the amounts.
You may receive your benefits through direct deposit, a Direct Express° card, or an Electronic
Transfer Account. If you still receive a paper check and would like to switch to an electronic
_ payment, please visit wwwgodireczorg or call 1-800-333-1795.
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What If I Have Questions? �
Please visit our website at www socialsecuriry.gov for more information and a variety of online
services.You also can call 1-800-772-1213 �nd speak to a representative from 7 a.m. until7 p.m.,
Monday ihrough Friday. Recorded information and services are available 24 hours a day. Our lines
are busiest early in the week, early in the month, as well as during the week between Christmas
and New Year's Day; it is best to call at other times. If you are deaf or hard of hearing, call our
TTY number, 1-800-325-0778. If you are outside the United States,you can contact any U.S.
embassy or consulate office. Please have your Social Security claim number available when you
call or visit and include it on any letter you send to Social Security. If you are inside the United
States and need assistance of any kind, you also can visit your local office.
190 STH ST E STE 800
ST PAUL MN
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 93 MERCURY License#: 716KY6 CN: 13272990 Invoice #: 24722
Date/Time Released: 12/26/2013 18:20 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00 �
Paid by: CREDIT CARD Admin Charge: $ 80.00 �
Released by: KAYLA 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 Y T REP RT ANY PR BLEM /DAMA E BEFORE LEAVING THE LOT
Signature 5i2000