Rivera NOTIC� OF CLAIM F�RM to the City of Saint Paul, Minnesot�
Minnesota State Stcrtute 466.05 stntes that "...eveiy person...w/�o clnin�s du»�nges_front nrry mt�nicipnliry...sha/I cm�se to be p�-e.cen/ed to the
gorerning body uf�tl�e municipcility wid�i�i 1�50 derys after tl��j�dleged/oss or i�tj�uy is discovered a irotice stcrti�rg the linre,pince,cr�ul
circumstances tltereof,nnd the amt�ttnt of contpensatinn or other relief demm�ded."
Please complete this form in its entirety by clearly ty ing 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 f'orm is received. The process can take up to ten weeks or longer depending 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�ti�l ;� Middle Initial�Last Name ��v�c� �F�F I\/F[�
Company or Business Name �A AI 1 � 7(!14
Are You an Insurance Company? Yes/�If Yes, Claim Number? K
Street Address S"� yg 2�s5E(,r l�v� S �'3
City IyIsNN�e-��ss State NtiN Zip Code �`f/b
Daytime Phone ( ) �� - Cell Phone (?�)�- 3$!0o Evening Telephone( ) �'� -
Date of Accident/lnjury or Date Discovered_�,�(' I? . 2v 13 Time 21 Z am/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 for your damages. oa '[:lEC 17a ZoYi
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f1�►D WH�QE S CA,J �l� �^-v Qa�2 AS z f�CKFD rv�Y caa P��l)1'' G�+as TECLSrvb W�E
Please check the box(es) that most closely represent the reason for completing this form: Co�'�'� .�►
❑ My vehicle was damaged in an accident O 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 vehicle was wrongfully towed and/or ticketed O 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 ihe 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 tick t issued and a copy of the impound lot receipt
O Other property damage claims: two repai�estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list o 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
I'ailure to complete and return both pages will result in delay in the handling of your claim.
All Claims- lease com lete this sectio
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, address s and telephon numbers: we¢�
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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 possible. If necessary, attach a diagram.
Nfd
Please indicate the a �unt you are seel:ing in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � 21`1 So �0�2 �rME �o►a ��e
Vehicle Claims-please complete this section ❑ check box if this section does not annlv
Your Vehicle: Year 2aoS Make K�! Model 1Z2'o
License Plate Number ( 2� State �Color �uL�E
Registered Owner �vB S�E�/CEP
Driver of Vehicle
Area Damaged N
City Vehicle: Year Mak ---^ Model ^
License Plate Number State -'�' Color —
Driver of Vehicle (City Employee's Name) --
Area Damaged
In'ur Claims- lease com tete this section ❑ check box if this section does not � 1
How were you iniured? �L.�R
What part(s)of'your body were injur•ed? T
Have you sought medical treatment? Yes� r No Planning to Seek Treatment (circle)
When did you receive treatment? / 7�� (provide date(s))
Name o f Me dica l Provi der(s): N �
Address Telephone
Did you miss work as a result of your �njury? Yes No
When did you miss work? !J (provide date(s))
Name of your Employer: �11
Address Telephone nl
�Check here if you are attaching more pages to this claim form. Number of additional pabes�
By signing this form,you are stating tlzat all informatio�z you liave provided is true and correct to tlze best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in proseciction. Date form was completed / / �'1
Print the Name of the Person who Complet : �;(,T�,�e,r�
Signature of Person Making the Clai :
Revised February 201 I
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-° � CITA�ION
�� ' nesota� Ramsey District Court
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M f� I IIIIII IIIII I�II IIIII IIIII IIIII IIII�IIIII IIII)IIIII IIIII Illu nll IIII �
�C ,43 620900201 fi43 �
State
_ � ❑MN ❑CDL
836 BARGEnr�""°
SA1N1 Pq�ry, ��+HNEL RG
6$i•Y66�5s420�'2450 �te zip
Mercha�,t t�: seesaseiaa
Term ID: �01�39d00080d6,3�Q
p Weight Sex Race Ethnicity
149V� � ; Make Type Model ._, Color
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� 7Aa�:idenUCras
�� ❑Properry ❑Injury ❑Fatal ❑Pedestrian �
�I� � ode ❑ Housing/Building Code N
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Owner ❑Passenger ❑Driver O
:! f �
� � -�� '�' {��f`-. N �
�� � tatute/ dinance �
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StatutelOrdinance A
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� Statut Minance w
�Y � I
� � _mph zone
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❑No Proof of Insurance 169.791(2)
i �� pe: ❑ Refused ❑ Breath ❑ Blood ❑ Urine
lp' Conditions �School Zone g
` 1 �1 'one ❑Commercial Veh. DOT# �
' '1 I �1 ❑Other
� � ID
' 1� I ❑Photo
� p I� r information on paying your fine. �
��� H; 0�0� / � i rivers License in Possession, Proof o lnsurance andior �
�3 ��I��I the Violations Bureau locations Iisted on the back of this f
� i �� he date the citation is filed with the C�urt.
flRpry
! d� � I this citation carefully and respond.
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n �ne ���
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, �45IQm`r, Cop c - . e�
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Officer,. ,__ -;, � _�r,�,. Citing�De�:
How Issued 1�In Pers. ❑Mailed�` ; Left at Scene
�
�, DEFENDANT I
To find out if your citation is payable without a court appearance,how much to pay,or to pay
your fine,choose one of the following methods: `• _
• Online: Access 2ndwebpay.courts.state.mn.us t
• By Phone: Call 651-266-9202 -
'You will need your citation number-VISA antl MasterCard acceptetl.'
• Mail Payments To: Ramsey District Court
Traffic Violations Bureau
15 West Kellogg Boulevartl-Room 130
St.Paul,MN 55102
Make checKs payabl2 t�� Ramsey Distnci Court
(A cnarc,e of up to�30.�0 will be assessed on all reiurnec checks)
---- — _- - _-----------------
Vioiations Bureau Locations
St. Pau! Court Suburban Court Law Enforcement Center
15 W. Kellogg B!vd., Rm 130 2050 White Bear Avenue 425 Grove Street
� St. Paul. P�N 55102 f��aplewood, MN 55109 St. Pauf, MN 55101
Office Hours: 8:OG AM -4:30 PM Monday- Friday(Excluding Holitlays)
Hearing Officers-By appointment only. Call(651-266-9202)
Paymeni and Penaliies s
If you wish to piead guiity and submit payment for the offense(s)on the reverse side of the citation,you must
tlo so within 21 days from the date the citatior is filed��vith the Court. It is your responsibility to present your
paymer�t in a timely manner. Plzase aliow 5 business tlays for processing.A�5.00 late fee is added to all
unpaitl fine balances.After 40 days from the date the citation is filed with the Court,an additional delinquent
fee may be added to ali unpaid fine amounts.
A.dditional Penalties may i��clude: 1) �eferral to the Department of Public Safety for tlriver's license suspension,
2) referral to a collections agency,and/or 3)arrest warrant issued.
If the offense is a petty misdemeanor,failu�e to appear will be consitleretl a plea of guilty and waiver of the right to
trial unless the failure to appear is due to circumstances beyond the person's control(M.S.169.91)and(M.S.609.491)
Appeal
' T�pkaU nc�guilty,a fo plead guiiry antl offer an explanatien,take the following steps:
�
! t)aft?r 10 business tlays,call 651-266-9202 to confirm that the citation has been filed with the Court,antl
2) request a hearing officer appointment. You must have a photo ID with you when meeting with a Hearing
Officer.
I understand that by paying this fine I am entering a plea oi puilty to this offense(s)and voluntarily waive the
following rights to:
a. a trial to the court, if offense is a petty mistlemeanor,
' 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 guilty 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 understantl that if this offense is a petty misdemeanor,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.
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ATr00001[1] .txt
z authorize the release of my Kia Rio to Phil ttivera
-Bob spencer
Sent from my Mobile Device. Please excuse any abruptness or typos in the message.
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