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Nguyen, Tanh NOTIC� OF CLAIM r�RM to the City of Saint Paul, Minnesota Mi�u�e.rntn Stute Statute 466.05 states�hat " ...every person...FVlio�•laims�Iuma�es./�roni nnv awnicipalrty....elral!cause ro 1�e pre.sented tn rhe guvernirtg bocly of the mnrticipulilv mithrit 180 dctys ct�'tr:r tlre alle�ed lo,�s or injtny is discovered a rtolice stntirrg 1lte time,plac•e,a�id �ircunrstn�ices thereof,and the a�rtnu�at n/contpensntinn or other reli�/demandc�d." Please complete this form in its entirety by clearly typin�or printing your answer to each question. If more space is neecled,attach additional sheets. Please note that you will not be contacted by telephone to clarii'y answers,so provide as much information as necessary to explain your daim,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 n�ture ot'yot►r claim. This form must be signed,and both pages completed. If something does not apply,write `N/A'. SEND COMPLETED rORM AND OTHER DOCUM�NTS TO: CITY CLERK, — 15 WEST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 I i�� .� �f I . i i ; .'�� F e . First Name i � Middle Initial � Last Name � Company or Business Name �� Are You an Insurance Com�any? Yes/N� If Yes, Claim Number? JAN 14 2�14 Street Address � � ��'� � � � � (`I��I ��K � Cit '�'�- � State Zip Code � y Daytime Phone ( ) - Cell Phone (� � ) °�`��- �-� � °`'Evening Telephone ( ) - Date of Accident/lnjury or Date Discovered_ Time am/pm Please sta[e, 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 emp�oyees are involved and/or responsible for your dam iges. '� � a ,��, `(�u �:-z: 1��: �€��r ._.�J't�, . . � ,3 . , . , _ _ ;� �. ,�_ - . ,, �r � � � ;. d��- ; , ;6 �� v.�� ;�,,,. � � �� o , '.Ne�f r�r s �a�� t� ., �: . _ s � � I V�,f c_3 � c. < Q "�" �'"__T /.x c,.b n 2 r �_< ,1 •. .� ✓�.� ��.'LC-'l f�r . . . , 4r E!%�r,_ ,;*f(m . J ) , _ . ..I � � S> _ .. IO4p ��'LCj�hr �R t.:�l'si�- ►�Gf'{.`��. . � � �..r Ple<<se check the box(es) that mosl closely represent the re�ison 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 �rMy vehicle was wrongfully towed and/or ticl<eted ❑ I was injured on City property ❑ Other type of Property damage—please specify • ❑ Other type of injury—please specify ln order to process your claim y^„ ^�� to include copies of all annlicable documents. For the cl�tims 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 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 rep�iirs; detailed list of damaged items O Injury claims: medical bills, receipts O Photographs are always we]coine to documem and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim rorm I+ailure to complete and return both pages will result in delay in the hundling of your claim. All Claims-nlease complete this section Were there wimesses to the incident? ��Y�,� No Unknown (c�rcle) _ , � r, � f' ,. . F;� � Provide their names, addresses and telephone nu��bers: `'`�" � � � ��t:�� J� ��F=�� ` `� ° �``��. � � . . . . � . : � � �. ; � � — �- Were the police or law enforcement called? Yes ��No`�� Unknown (circle) If yes, what departmeni or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facitity, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. L -,! . .._ � Please indicate the amount you are seel.ing in compensation or what you woulcl like the City to do to resolve this claim to your satisfaction. �a ��_ F�� . 'y� ,� ;�� Vehicle Claims—please complete this section ❑ check box if this section does not applv Your Vehicle: Year � Make Model � � ? License Plate Number State ."-"' a�' Color � ��' ' Registered Owner � - ` -' Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In_jury Claims— �lease complete this section �check box if this section does not ��ply 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 treatme�t? (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 work? (provide date(s)) Name of your E►nployer: Address Telephone C� Check here if you are attaching more pages to this claim form. Number of additional pages_�- . I3y signifag tltis form,you are stating tlaat ull inf'ormatioft you have provided is trcre cznd correct to tl�e best of your kfiowledge. U�:sigjied forms will ftot be processed. Secbmitti�ig a false claim can result ifz proseciction. Date f'orm was completed � ;' �--� -� �f°f-° � ''- r 1 ;' � ' ` . R I'rint the Name oF the Person wlio Completed this For�n: � �� t � Si�;nature of'Person Makin�; the Claim: �::.,y, Revised Februury 201 I O O O \ N \ � �`T\ M � F N N J N � � _ � V � O � � i.[) O � H O O) � M O 11) � p r Z � � r � � � N N � 64 b9 E!? d�? E!J Ef3 d-} Q � W J � � N W � � N � � N � U ` � \ i N � � � � -C � j, O N � � U c°• � � � L m > t� U rn c C o � V � W r � �� X � i (� � . 0 N H (n Q F- (n fI) I-- Z � � M Q � 0 N > � y .� � C � U � n �� y W .0 � � � fl."_' m � � O N J U 'C � N � � � � V '� � a � N � fl- � S � Z } c� � � � n U Z a� t � rn Q C� o � o � � � o � O � � >+ N � N — F- } � OMO u�i �n > � � � � -c LL C � � L 3 C � � a O U N � � U U N �- W J � � �� E ,� � M � � j — � O T L � . � � � � N > � rn � O � � 2 p � U � a�-. � Q- � � Q � � � � � � � � om � a� > ° a�'i �c � } � r oC > � � a'�' N � oC � O v a�i O U � :� a0 �° � � O �p p � ~ � ¢ � > � � � ,o � � } � Z � � � � �� p ° n � � U � � � � � .Q � Y 0 � � � � Q W = i (� F-' � a O � y �, y C t c�6 a � !A � � � � +• � Rf � � � U .0 �, c� •- (C V �i c� � Y � N :a � � = c�'a .� � +�-� � 'o O � � � � oC � o�[ - � � cn � o � a HI � i I � IIIIIII I II II III III IIIIIII IIII IIIIIIIIIII IIIIIIII INCIDENT INFORMATION REPORT /14/20141 STATE OF MINNESOTA COUNTY OF RAMSEY DISTRICT COURT INCIDENT AND CITATION INFORMATION INCIDENT ID PAYMENT PLAN CITATION NUMBER 2728417 , 620900172667 DEFENDANT NAME TANH MINH NGUYEN ADDRESS 2953 MCKINLEY WOODBURY MN 55125 DEFENDANT INFORMATION DATE OF BIRTH 12/12/1961 GENDER MALE HEIGHT 5 Feet 6 Inches EYE COLOR BROWN WEIGHT 150 Lbs. DL NUMBER F596056971920 DL STATE MN RACE ASIAN HISPANIC (Y/N) OFFENSE INFORMATION DATE/TIME 12/05/2013 09:28 DIVISION RAMSEY COUNTY LOCATION WS MENDOTA BTWN COOK & COMMUNITY ST PAUL YORK AGENCY PUBLIC WORKS METER ISSUING METHOD LEFTAT SCENE OFFICER 1 845 CN 13258617 OFFICER 2 NBRHOOD VEHICLE INFORMATION PLATE 062AJR MAKE HONDA - STATE MN MODEL ACCOR PLATE YEAR 2014 COLOR RED VEH TYPE PASSENGER VEHICLE VIN 1 HGCG2258YA027158 VEH YEAR RESPONSIBLE PARTY ID METHOD NONE OTHER SYSTEM IDENTIFIERS CN NUMBER CHARGE INFORMATION STATUTE/ STATUS REASON JURISDICTION ORDINANCE DESCRIPTION CLOSE FNSUS STPAUL 161.03 Snow emergency parking restrictions ORIGINAL FEE INFORMATION AMOUNT DUE $40 FINE 40.00 $40 FINE .00 LAW LIB PARKING 3.00 LAW LIB PARKING 00 Srchrg-2nd District 1.00 Srchrg-2nd District .00 Srchrg-Parking 2009 12.00 Srchrg-Parking 2009 .00 GRAND TOTAL 56.00 GRAND TOTAL .00 OFFICERS COMMENTS DAY PLOW WINDROW