Hope NOTIC� OF CLAIM FQ►Rl�i to the City of Saint Paul, Minnesota
llliniiesntu Stute Stat��te 466.05 states thnt " ...ei�e�y perso�a...�vlio clnim.c durnage.c./i-nnt a�iv municipaliry...slraN cause Io 1�e presc��ued tu tl�e
go��errtirrg 1�udy q(llte mmiicipality�+'itlti�t 180 d�n�s n�lc:r thc alle�ed/nss or injw-��is discovered a rtotice stnting tlic time,plure,a�id
�ii-cun�stn�tces tlrerc o/;and tl�e amowtt n/con�pensntirni nr nther relie��dentnnded."
Please complete this form 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 answers,so provide:�s
much information�is necessary to explain your claim,and the amount of compensation being requested. Yoi� will receive a
written acknowledgement once your i'orm is received. The process can take up to ten weeks or longer depending on the
n�ture of your 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 KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �-��^S�✓� Middl�.Initial �Last Name ��_l-�'. ���������
ComPany or I3usiness Name ��'� 1� ����
Are You an Insurance ComPany? Yes/No If Yes, Claim Number? (��T� �'��F�K
Street Address v2�' � -�
c�ty G�� �� �'��.�.L sc��ce /�/`J z�� c��a� SS e� �'
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Daytime Phone��) � vc3-��Cell Phone ( ) - Evening Te]ephone ( ) -
Date of Accident/lnjury or Date Discovered_ ��(��! �� Time II ��� �I/pm
Pleuse 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.
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Please check the box(es) that most closely represent the reason for completin�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
gl My vehicle was wrongfiilly towed and/or ticketed ❑ I was injured on City property
❑ Other tyPe of property damage—please specify
• ❑ Other rype of injury—please specify
In order to process yol�r claim�u need to include copies of all applicable documents.
For the claims types]isted below, please be sure to include the documents indicated or it will delay the handling of
yo�ir claim. Documents WiLL NOT be returned and become the property of the City. You are enco�iraged to keep a
copy for yourself before submitting your claim fonn.
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
I�'ailure to complete and return both pages will result in delay in the handling of'your claim.
All Claims-nlease comnlete tl�is section
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Were there witnesses to the incident'? Yes No �nknown j (circle)
_..
Provide their names, addresses and telephone numbers: � -��� �"�"�
Were the police or]aw enforcement called? Yes o Unknown (circie)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place`? Provide street address, cross street, intersection, na�ne of pnrk or facility,
closest landmark, etc. Please be as detailed as possible. If necessa�y, attach a diagram.
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Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. -�w �;�r �a.�.�:1 ��c o�( �' -�� (iY� ,� ��c���- �=v{�c��
Vehicle Claims-please complete this section ❑ check box if this section does not a�ply
Your Vehicle: Year�l) iJ Make ' Model C�.�� l�c�..
License Plate Number����� State_ �)o`' Color Cs�-
Registered Owner �\��.r,) �1 ��s� �
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- please complete this section ❑ check box if t�his tiection doe5 not apply
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 treat�nent? (provide date(s))
Name of Medica] Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Na�ne of your Employer:
Adclress Telephone
❑ Check here if you are attaching more pages to this daim form. Number of'additional pages
By sigriirig tliis forrrt,yori are stati�zg tliat�ll informatiori you laave provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
� S�ibmittirtg a false claim can result in prosectetion. Date f'orm was completed �� ��("('
Print the Name of the Person who Completed this Form: �G`���� `Tl�
Si�;nature of Person Making the Claim: �c� ��
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Revised February 201 I
I �i���� �-
' CITATION
� State of Minnesota Ramsey District Court -
City of �
�'
Citation# I IIIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII)IIIII IIIII IIII IIII
I620900203522 s2osoo2o3�22
�
DL Number State
❑MN ❑CDL
Name
First Middle Last
Address—Street, Apt#
City State Zip
DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity
Vehicle Licen�e,Nq. Piate Year State Make •��� Type Model Color
��� - ..$-'.t_,. �4"� <�,.� 'i t.,� x F� s .r. � ,; f.'�F'�.
Date of,Offense. Time-ot Offense ' ❑AccidenUCrash
� r '"; � j � ; . ❑Property ❑Injury ❑Fatal ❑Pedeshian �
Parking Meter-Number Neighborhood Code _❑ HousinglBuilding Code N
0
❑Booked �Par�ClOperate ❑Owner ❑Passenger ❑Driver �
Offense Location �
N
.Vr� ,��' ,, a F� � 3 'yJ n O
NO 1 Offense � StatutelOrdm2nce �
' lwf'd,-f . d 'C�...y�4r. ,,.. ....F �
� No 2 Offense � Statute/Ordinance r �
� N
NO 3 Offeflse Statute/Ordinance
I ❑S eed 169.14 subd ): mph zone
� P (
� ❑No Seat Belt Use 169.686.1(a) �No Proof of Insurance 169.791(2)
I AC Taken—AC: Test type: ❑ Refused ❑ Breath ❑ Blood ❑ Urine
❑Hazardous Material (DOT) �Unsafe Conditions' ❑School Zone
❑Endangering Life & Property ❑Work Zone ❑Commercial Veh. DOT#
Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other
I See back of citation for information on paying your fine.
jIf cited for No Proof of Insurance or No Driver's License in Possession, Proof of Insurance and/or
Driver's License must be shown at one of the Violations Bureau locations listed on the back of this
Icitation within 21 days from the date the citation is filed with the Court. �
f Please read the back of this citation carefully and respond.
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`; Officer(s)Name(s)
Officer No s CN#-�; -~;� -� CitingfDept�,;,,„�
� �• .f� ��� f �+��c _ �: .�"f:
How Issued ❑In Person O Mailed� C1Left atSce�e
y DEFENDANT
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� 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.courtsstate.mn.us
- • By Phone: Call 651-266-9202
`You will need your citation number—VISA antl MasterCard acceptetl.'
• Mail Payments 10: Ramsey District Court
Traffic Violations Bureau
15 West Kellogg Boulevard-Room 130
St.Paul,MN 55102
Make checks payable to: Ramsey Districf Court
(A charge of up to$30.00 will be assessed on all returned checks)
Violations F3ureau Locat9ons '
St. Paul Court Suburban Court Law Enforcement Center
_ 15 bV. Keliogg Blvd., Rm 130 2050 White Bear Avenue 425 Grove Street
St. Paul, MN 55102 Maplewootl, MN 55109 St. Paul, MN 55101 ,
Office Hours: 8:00 AM-4:30 PM Monday-Friday(Exclutling Holidays)
Hearing Officers-By appointment only. Call(651-266-9202)
Payment and Penalties
If you wish to plead guilry and submit payment for the offense(s)or,the reverse side of the citation,you must '
do so within 21 days from the date the citation is fiied with the Court. It is your responsibility to present your
payment in a timely manner. Please allow 5 business days 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 adtlitional delinquent
fee may be added to all unpaid fine amounts.
Additional Penalties may include: 1) referrai to the Department of Public Safety for driver's license suspension,
2) referral to a collections agency,andlor 3)arrest warrant issued.
If the offense is a petty mistlemeanor,failure tc appear v�ill be consitlered a plea of guilty and waiver of the right to
tr�al unless the failure to appear is due to circumstances beyond the person's control(M.S.169.91)and(M.S.609.491)
Appeal II
t
To plead not guilty, or to pleatl guilry and offer an explanation,take the following steps:
1)after 10 business d2ys,call 651-266-9202 to confirm that the citation has been filed with the Court,and
—_ _ __
2'� request a hearing officer appointment.You must have a photo ID with you when meeting with a Hearng
Officer.
I untlerstand that by paying this fine I am enterina a plea of oailty to this offense(s)and voluntarily waive the
following rights to:
a. a trial to the court,if offense is a petty 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 guilty beyond a reasonable tloubt,
e. confront and cross-examine all witnesses against me,and
f. either remain silent or to testify in my own behaff.
I also understand 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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