Tinkham NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Mrnnesota Stnte Statirte 466.05 stntes thnt "...every person...who clnims dmm�ges fro►n nny municipnlity...shnll cni�se to Ge presented to the
governing 1�ocly of the m�micipa/ity within 180 days after the a/leged loss or injury is discovered n notice stating the time,place,nnd
circcrmstances thereof,nnc!tlTe amount of compensation or other relief demnnded."
Please complete this form in its entirety by clearly typing 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 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 DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �LaSAt�l Middle Initial, �1 Last Name�l IU�.(-�pM
Company or Business Name
Are You an Insurance Company? Yes '�T�o If Yes, Claim Number?
Street Address 21v� �� W.��"�` «" �ZD �
City �i �AU t� _State M t�� Zip Code O Z
Daytime Phone ( ) -
Cell Phone (1��1)�Z�-J27�Evening Telephone( ) -
Date of Accidend Inj ury or Date Discovered � �.T��(� Time =ry 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.
My �-Arc. �A� �'�� r� Fa�M A nay ��w �►��e.�►��3 ��1� r.���+�- `i i�06 oM� �• I cau��n
n��t� TN� ��GK.�`l WA4 i�i51✓1��5�I A li1 { �. D1. �
1
i�LJ��iT_J 1�N1��„�f-� �,�/ �-1��.1�2T�Ls �4.12)W 1�1�(�L}EN!Lf T���IG AN+� T't�t�J iNL, [DO��ATo�
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 damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
.1�'My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
O Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all analicable 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 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 esti�ates if the damage exceeds$500.00; or the a�ctE C1E I V E D
and/or receipts for the repairs; detailed list of dan�aged items
O Injury claims: medical bills,receipts . �N 21 2���F
O Photographs are always welcome to document and support your claim but will not be returne
Page 1 of 2—Please complete and return both pages of Claim Form C�TY C L E R K
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please comulete this section
Were there witnesses to the incident? Yes No Unknown ) (circle)
_. _. ,
. . �___.__
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknow (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.
U�-►►��� °7}�^ S-t (i�1 � �M�i�I ��E �►.l GN�i�v u`T' ��r�sT s��:
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. Z i�,oU — To i,�l �E��
Vehicle Claims—please complete this section �,check box if this section does not a�plv
Your Vehicle: Year i�`�Io Make �i��c_l� Model 1�CsA' �
License Plate Number Io�KZI� State 1y.p�_Color S�L�l
Registered Owner 1✓tAR.�(_i :T�t�Kk-IAM
Driver of Vehicle SVsRN TiN v�A�
Area Damaged ►o W E:�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims—�please complete this section �check box if this section does not anplv
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 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,you are stating that ull 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 ��Zl ,i�
Print the Name of the Person who Complete this Form: S � T��1�{�'
Signature of Person Making the Claim: `
Revised February 2011
a o �Y 3
a �� o �n'
. a c � '"'i s K -
.'c a cr� - .,,a
� ' s� "' ". co
�' y" 'rt cn
0 0 ?;� ¢,�, y
m r° za��-
' � � � -�w--�
� c-^ w a, m
�o
n E 0 O D W D
� N JA 00� (J�CDC
-' V/��� mw �r�r
D O �y �m n; T r+
� T �� p�-+ T 3 3
0 D O!Z t±�
� { r+-e � m a � Dx o�
� 7 mcnzz
'� � �cnzc
G � -a � � iv F+m
a +si
't i, �.r r
— 3 Ja -J O
fp 6 � �--1
�-� �t (P h C
0 � A
� � ` _�
6
__ �� __
f�1
@ 1S . F� E
�o-' c° v
m w cJ+ �o
m N la� Q
cn -I � p o a Cn � - :_«
c� O ° a� � su a� w �. � m � m � � A�i
a� � �� � � � �`< _ � m Q: c� � �- .
� � � � N � � � � � � � � � � �
�
m m �m � p 3 c m � � Q n Q �' � �
� � a � a o � �.�. .a m o � c c
� � � o� � �� � � m y � p m �T. �
O n. ° � � fD m m Q- -{ � � �
C m � o� OQ- ?: � _ � �p n•
n
�
N A Sv
�J � 'O SU �N ? � (�D r � Q �
� � � �' � 3 � � �p � � �
� 1 �
—� � S O 7 fn A� � N �
IoZ .. �. (D — (�D A� fp O �
� � � � �� Q. � r Q
m i—
� -a v' � � p � 1 0
� 'l'i � � � � � � N � �
� 7 � O � A> < tn
� N � c�D � ai � � � �p �
fn O � �'`�
Z Q. _' O c� � O
� � � '�-. �' cD
� Z O � � � Q W �
�l Q �• � � n � (Q
� r � cn � �. z (D
W °� °Q � m C�
m �, o � 3Q- �'
� p N !U A�
� � .-�i. � � n �
D - � � o z �
m
�
� � ° o
D Z O m c � Q � o m° �
m � � � � x � ° g .� Q
m � � � �' � � m � CO <
a� � m
�
� J � � .. � � S � �
m N � o � jv (D C�
cp " .. � CD
r �
m �
D t� � � tfl t�
< c� � cp
Z N N ,� � � �
� � � � Cli O 0 W O (p
2 p o p � O � � � O
m � �
° 0 N
.� Ui
N
N
�
�
N �,,,�.....
O
O
O
,
�I�1���ON l
State of Minnesota Ramsey District Court �
City of !
Citation# I(IIIII IIIII IIIII IIIII IIIII IIIII IIIII III�IIIII IIIII IIIII IIIII IIII I II
I
620900208048 620900208048 �
i
DL Number State +
❑MN ❑CDL j
Name �
First Middle Last
Adtlress— Street, Apt# �
City State Zip �
DOB(mm/dd/yyyy�,,,�yes Height Weight Sex Race Ethnicity f
�
Vehicie License No. Plate Year State Make Type Model Color �
, -, , i ,, ,, t �
Date of Offense Time of Offense OAccidenUCrash �
'` ' ❑Property ❑Injury ❑Fatal ❑Pedestrian � �
Parking Meter.Number Neighborhood Code ❑ Housing/Building Code
� �
� �
❑Booked ❑Park/Operate ❑Owner ❑Passenger ❑Driver O �
Offense Location Q {
N ;
NO1 Offe11Se Statute/Ordinance � �
.>r : .
, . � '
�. � ,` � � � �
No 2 Offense s�amteiom��a�oe �
GO �
No 3 Offense Statute/Ordinance ;
�
t
I
❑Speed 169.14(subd ): mph zone i
❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) �
AC Taken—AC: Test type: ❑ Refused 0 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 �
See back of citation for information on paying your fine. �
If 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 �
citation within 21 days from the date the citation is filed with the Court. �
Please read the back of this citation carefully and respond. !
�
�
iI
E
i
i
Officer(s)Name(s) �
,... ;
Officer No(s). CN# ;:.., yCiting Dept j
�
How Issued ❑In Person ❑Mailed OLeft at Scene �
i
DEFENDANT ' �
�