Donahue NOTIC� OF CLAIM I�'ORM to the City of Saint Paul, Minnesota
Min�Tesntu Slute Stnttrte 466.05 stntes�hat "...everv persrni...whn claims dnmages./rom n�tv inunicipnlity...shufl cnuse tn he pre.se�rted tu tlTe
��o��erning bucfy q`d�e municipn/iry x�i�hiit /80 duys cr/�ter the n/Ieged/nss or inj�uy is cliscnvered a nntice stnting the�ime,p/nce,aitd
circun�stances tlrereof;nnd tl�e nnrnunt q�corrtpen.cntion or other rFlref denrnncled."
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. Plcase 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 Rcknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This f'orm 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 � ��/ti Middle Initial�Last Name�o n�.h v�� .�..—...��` ,��
�
Company or Business Name ��^.:
JAN 2 8 2Q14
Are You an Insurance Company? Yes No If Yes, Claim Number?
stree�aaares� � 1 � 1 1-� �,ml��n-e, Pev� t�l �� �a, 1-�- CiTY CLERK
City ��.�Vl ' State � � Zip Code 5�i �V
Daytime Phone ( ��- Cell Phone (b5� �5=�15 Evening Telephone ( ��-
Date of Accident/lnjury or Date Discovered ���g � 3 Time �" a pm
Please state, in detail, what occurred (happened),and why you are submitting a claim. Please indicate wh or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. I a 1 1�J
�IYDY� v`\\�' �D -ec� • � SY1o� c ' S
�tY� -e, E c�.. v�► t a w o t�. S -t, n'�
S t-r�e�. t �S t�v�e d (, - d ho r�
� � A.� Grn o a 4 2 �
� � ,�, i r�
Y � G�' � � S 0 �
rn�+n�rr �C o�i,�.n r t ol 0.+tY�au-+'�t•
Please check the box(es) tht�t most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged durinb a tow
❑ My vehicle was damaged by a pothole or condition di the street � My vehicle was damaged by a plow
�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 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 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]ist 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 pages will result in delay in the handling of your claim.
All Claims—nlease complete this section
Were there witnesses to the incident'? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enfarcement 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.
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. • '0 i( 0 lN�
o-t-� ' �
Vehicle Claims—please complete this section ❑ check box if this section does not applx
Your Vehicle: Year Make Model
License Plate Number State 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—alease complete this section C�check box if this section does not a�ly
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 moi•e pages to this claim form. Number of additional pabes�.
I3y signing tltis form,you are stating llzat ull information yoz� liave provided is true and correct to tlze best
of your k�aowledge. Unsigned forms will iiot be processed.
Submitting a false claim can result in prosecection. Date f'orm was completed � I a } a v� �
Print the Name of the Person who Completed this rorm: Y[1�� (/L I� 1 . l J l7�G'l�'1 l�'�—��
Signature of'Person Making the Clairr�: L� �
Revised February 201 I
Lrl 1 !-1 1 IVfV {
Smte of Minnesota Ramsey D1sVict Court
City of " �
Citation# I�����III��I��II��IIIIII�IIIIIIIIUIIIII����I�II '
620900203968 620900203968 - i
DL Number State �
❑MN ❑CDL 'i
Name
Frst Middle Last I
Address—Street, Apt#
City State Zp i
DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity �
�
Vehicie License No. Plate Year State Make Type Model Color �
_ r"�� � � d
Date of Offense Time of Offense AcadenUCrash i
❑Properry �injury ❑Fatal ❑Pedestrian
Parking Meter Number Neighbofiood Code ❑ HousinglBuilding Code N `
� i
❑Booked ❑Park/Operate ❑Owner �Passenger ❑Driver O
Offense Location ` Q ;
'_ � - - � _..��'=-� ' � N I
No 1 Offense _ scaw�orana�ce � !
No 2 Offense ��^�� � �
�
� �
No 3 Offense 5��� '
❑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: ❑ Refused ❑ Breath ❑ Blood ❑ Urine
❑Hazardous Material(D0� �Unsafe�onditions ❑Schooi Zone
❑Endangering L'rfe&Properly ❑Work Z e ❑Commercial Veh. DOT# �
Idenfification: ❑DL ❑DVS Web ❑Photo ID ❑Other ;
See back of citation for information on paying your fine. �
� li cited for^Jo Proof of Insurance or No Drivers License in Possession. Proof of Insurance and�br i
C�river's ucer,se must be sno;vn a!one of th2 Violations Bureau locations listed on the back of this l
citation within 2? davs?rom the date the citation is filed�vith the Court.
Pfease read the back of this citation carefully and respond.
I
�
;
�
4
i
Offlcef�S)Nd(TIe(S) �
Officer No(s). ,. ;, -; CN# F; , CiUng Dept �
How I&sued ❑In Pcrson ❑Ma�ed Qteft at Soene
, !
_ �
DEFENDANT �
^ Oniine: Access 2ndwebpay.courts.state.mn.us
• By Phone: Call 651-266-9202
'You will need your citation number—VfSA and MasterCard accepted."
� Pdlail Paymenis To: Ramsey District Court
Traffic Violations Bureau
151Nest I<elfogg Boulevard-Room 130
St.°aul,MN 551Q2
Mal<z rhecks payable to: �zrs�;r Distr+;cf�oi!r�
(�cl;arg,_ of up to$30,00�.�iil!be sssassed or�;I! retumed ch?cks;
!rioiati;�r.s Bureau Locaticns -----i----------------
St. P?ul Cour �!�burban Court La!«�niorcement Center
15 l'�. Ke!iogg Bivd.. Rm ?;0 205D INhite Bear Avenuz 425 Grove Street
St. "raui, (�4��1 55102 i,�ianle�•�ood, i1�fd 55i0�� �i. Paul. t�N 55i01
Office Hours: 8:00 AM-4:30 Pf� �JOtiOa�-r=�ld'ey(Exciutling Holidays)
Hearing Officers-By appointment onl�. Cali(651-266-9202)
--
Payment and Penalties
If you mish to plead guiibf ard submit payment for the offense(s)on the reverse side of fhe citation,you must
do so�;�ithin 21 da��s from the tlafe the cifaiion is iilad�vith the Court. It is your responsibiliry to present your
paymer�t in a timely manner. Please allow 5 business tlays for processing.A S5.00 late fee is added to all
unoaid fi���balances.After 40 days from the date the citation is filetl�vith the Court,an additional delinquent
fee may be added io all unpaid fine amounts.
Addition2l Penaities may inciude:i�referral to the Department of Pablic Safety for driver's license suspension,
2)referral±o a collections agency,antl/or 3j arrest warrant issued.
It tne offensa is a petty misdemeaiior,failure to appear will be consicler2tl a plea of guilty and wai�rer of the nght to
iriai unless ih�failure to appear is due io circumstances heyontl the person's controi(ivi.S.1G9.91)antl(�ri.S.609.49i;
Appeal
To plead rot guilty,or to plead guilty and offer an expianation,take tne foilowing steps:
1j aner 10 business days,call 651-266-9202 to confirm fhat the citation has been tiletl with the Court,and
2) req�est a hearing officer appointmenY.`(ou m�ust ha};e a photo ID��;iih��ou i:�hen meeting�+vith a Hearing
Officer.
i understand that b,paping this fine 1 am enterin a piea of pui�iy to this ofifense(s)and��oluntarily���an�e 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 mistlemeanor,
c. representation by counsei,if the offense is a misdemeanor,
d. a presumption of innocence urtil proven guilty beyond a reasonable doubt,
e. confront and cross-examire all witnesses against me,and
f. either remain silent or to testify in my own behaif.
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.
.
Date/Time Released: 12/18/2013 08:24 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by:JAMES Tax: (7.625%) $ 15.55 --
/ n"..`�
I,the undersigned,have recovered the vehicie described above. Subtotal: $ 219.50 , ``�
I wiil 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 YOUR RIGHTS, REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature ' si2000
_ —__I._.._.._-._.._�_
S7 PHUI IIf'OlM1 LOT
830 BARGE CHANNEL RD
SHINT PAI�. tkl. 55167-245E3
651-'266-5642
Mzrchant ID: BO(j63l30144
Tera IU: W1739000Gf88063�S1+:��1U•
Sale
zzzzzzz�nonoc61�2
VIS� Entrv Method; Sriu�d
iotal: � 219.�
12�18�13 48;24,24
Inv a: �f39 A�r Cod�. ��54
Rc�rud: Online
c�to.,�� cau�
rwa� rou�
Ramsey District Court
RECEIPT
Date�me: 1/23/2014 10:43:33
Defendant: DONAHUE,ALICIA MAE Receipt No.: 2149036
Payor: SLICIA DONAHUE Location Paid: MAPLEWOOD
Citations: Amount:
620900203968 17.00
Amount to Be Refunded: 0.00
Total Amount Paid: 17.00
Method of Payment: CASH
Check Number:
Comment: TENDERED$17 PAID IN MAPLEWOOD
I
II
KEEP THIS COPY FOR YOUR RECORDS