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Olesen-Rettinger ����� 1 �� � NOTIC� OF CLAIM FORM to the City of Saint Paul, Minnesota Mrnnesntci Stnte Stunrte 466.05 states t/urt "...every persnn...who clni��rs dcimages frone any mi�nicipaliry...slzrrl/crr�.ise to he prese�ued to�he go��erning hur/y of!he m��nicipulity x�ithin 180 duys nfter t/re n/Ieged loss or injury is discovered u notice stnti�r�the lime,pince,a�rc! circwnstcrnces thereof,and!!:e crmoimt of compensatirn�or o[her relief denrnncled." Please complete this form in its entirety by clearly typing or printin�your answer to each question. It'more space is needed,attach additional sheets. Please note that you will not Ue 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 ot'your claim. 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 �f` �'r Middle Initial � Last N1me Q��SPY1 � ���"�"1�'1G1e'1� Company or Business Name A��l�} �'��cIVED Are You an Insurance Company? Yes/No If Yes, Claim Number? �8 ��,�� Street Address �� D� /�CtC�S`k� �J`�e� �� S��t�Y CLERK City ,f(T�' •( State Zip Code_�_ Daytime Phone ( ) - Cell Phone (�)�- �IL.�Evening Telephone ( ) - D<<te of Accident/Injury or Date Discovered�I%SII��?�o�3 Time ��� a^ /pm Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you � �1 the City of Saint Paul or its einployees are involved and/or responsible for your dam• es. -+-am �ebrn.t-FhlY CIa���f ,` -�o y 2 ' � i t���C.a, � brc�1'r+81'' tiCt'ff I� �.r�it^ d�Vt C cL Wee� �i�l !� S°f' '1 �0 � CR1'' 't YP GrLI Y �'Lf1U`� • 5 5�2�r'� r t? �`rn t1 'twy+¢n ehec(�e` -YZS�d-`�-PrmcU.� n'�e`faz�pC Bn Chr�` -k-ir et -� lu � . t-Ue be2�1 in 0'tl ou `a� �c{'lc�Gt.t� ntt,c�r+, ,� �, 2 �e ► �n,a�v +' -fr� a s�n,cav .Pirn��' , � rw uS . 2�vwz�r��.c " � Please check the box(es)that most closely represent the reason for completing this form: �prt.11 ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow (,` � b ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ��i�(� �'My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property 4��eac� ❑ Other type of property damage—please specify {�,,,�m�• ❑ Other type of injury—please specify ,S" In order to process your claim you need to include copies of all applicable 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 bilis 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 's,�.��-�.., z_ �� � Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease comn�ete this section Were there witnesses to the incident'? Yes N� Unknown (circle) Provide their natnes, addresses and telephone numbers: � Were the police or law enforcement called? Yes � Unknown (circle) If yes, what department or agency?_��1 .A- Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or flcil�it�y, closest landmark, etc. Please be as detailed as�ossible. If ne ssar , attach a diagram. ��[��i!%jT,l -�9��i �QC � �' t. � �S Z?S GY 0 Piease indicate ihe amount you are seel:ing in compensation or what you would like the City to do to resolve this claim to your satisfaction. i Lt> tt � e � �2Cq.50 Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year �oog ? Make un ' t Model �GTlLn:�'GL License Plate Number SS • i � State N Color rei Registered Owner �� �� '✓ �S Driver of Vehicle � �'"� �►" o�' Area Damaged City Vehicle: � Year Make o� N I� License Plate Number S e Color Driver of Vehicle(City Employe 's Nam ) Area Damaged In'ur Claims— lease com lete this section � ❑ check box if this section does no[ a 1 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 Tetephone 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 ou are attaching more pages to this claim form. Number of additional pages 1f� . � p�c.o�LO�-u,� U�e,e,i2, � f�►�t� � By signing this form,yd�i are stating tltat all inforrrcc�tion you hav provided is trcce d orrect to the best of your krtowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed �� z g�'�4 Print the Name of the Person who Completed this Form: �Y �— ��G — r`�' � Signature of Person Making the Claim: �� � ' Revised Februtuy 201 1 ` ����C�� � � � �� I'ailure to complete and return both pages will result in delay in the handling of your claim. All Claims—alease complete this section !^� Were there witnesses to the incident? Yes �`J6 J U known (circle) Provide their names, addresses and telephone numbers: ��J Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency?�1 Case#or report# /v Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest landmark, eic. Please be as detailed as possible. If ne e:sary, attach a diagram. , C PE?� t�/R� '��" LC,CG� �'Ul SS/OS � Please indicate the amount you are seeking in compensation or w at you would like[ e City to do to resolve this cl:a,im/ to y,our satisfaction. --�- (�(J � `fhQ '-�&U.�l� �S !"Of"3tP GC �'D�' �-I'ha`s cc�Q � re irn� rs��, irn r � .� � Z . O Vehicle Claims— lease com lete this section �F c � � check box if this section does not a 1 Your Vehicle: Year 2 L Make � Model �Ql2�,t '. License Plate Number q State��Color C C�LJ Registered Owner � �h� br�`t-�¢�' Driver of Vehicle (!.�P,r �tJcZO Dc�Y f��E� I n Oyti�" YYC.C�-�O (5� Area Damaged ity Vehicle: Year Make odel �, 1 License Plate Number te Color Jv/� Driver of Vehicle(City Employee's n e) Area Damaged In'ur Claims— lease com lete this section ❑ check box if this section does not a 1 How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes 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? es No When did you miss work? (provide date(s)) Na�ne 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 tltat 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 f'orm was completed �— �-����_ Print the Name of the Person who Completed this Form: NI�'r 1-- o � e en - R�-�-hl� � , �� Si�;nature of'Person Making the Claim: ' Revised February 201 I ���.�. l �� , s�� . � -�� --. � 1 0 � o � � o L N O � � 1.1_ � � �' � M � N O � � J � O M O O t1� � O ll� 2 > N p O � � � � I- N C r- 00 � N O � Vr N V b9 69 69 69 � 6q � ; � � ¢ > °� � I � � s � � � � � i ca �n � � � U L N '� `- �. 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MN. SS1E17-2450 651-266-5G42 Mei.f�ant 1D: eGklo3ii(914q 1����� IU: util f34Eft]0fl3uii63a�3144ub S�le zzzzkz�zzzzz8243 4�1SR Entrv Method: Swiped R��ou�it; $ 219.54 1az: S 0.4� -_-- - iotal; g P19.5�,, 12�26�13 �9,�2;4? Iov �; ���jJ�li pa;,. '�:1e: i"�;a RpPrvd: Oi�line c�,st:,�,�r� c:,,., ThiANK YOU! i � . .. . . . . . ...... .__.. . .. . . ♦..._.... .. . ....... tQ O � � � � A) p�j �L, 3 (�D A�, (D � A� � ^� � ���G = (D (D Q (D (D � � A1 � (p (Q N � � � � � N � y � � •�-r � p 77 � O � c m c�i c�p �- (7 � c�p 2 Au � � � � � � n � tn � �1 O � � � n � °" � � ° � 3� m -� � z � -1 0 -.. o �. � m � � p � � Q s o � v Q � s m � O � D �• C � cp m c'� � � y a (D � � � � � � � '� 'a Sv 3 N _ � N � �N o �• � 3 m o � �, -v = m c°� � � °" o � � -� � � °� � �' 3 m No � o �D. m - m w m W � ?� a r r m oN � � o � o°o � o � � �p � a � � � � m °° � �° —1 cp N <p cn �G � � O N � Q � O n � n p � � � Q � � � Z � �, � �° N � � ]7 0- = N o �. -< � � f—t ..« � � n (D O �p � W �-a Q a �' � � � � � �' n � Cn ~� � � � z m � W � D ° iv � o m c � a � o r�v � � � f� O � � Q x 3 ° � � Q' m �' o � � cQ C) o C m � 3 � w °' � � � cu �O � � a��i o �' a�i � c��' 7� ai cQ �°\- m cQ � m .. � .. � 7J r cp m D r� � � � � r� � � i < � Z � p � � p O �N 0 (D ' O 2 0 0 o cn o � v, � O m N � r O � w � � -A` 1 �v � � � N O O O � �� �\� � sT PqUI inPOUno �ur � t� b3� BARGE CHANNEL RG SAINT FAUL. MN. 551d7-245k1 651-266-5642 Mercharit TD: 8bb638F114q �/"" 0 lerm ID: �l�li'340ki00f3�063£tb144k�6 Sale zzzzzzzzzzzz7166 UISA Entrv Method: Swiped Amaunt; 8 219.5� iaz; $ Q.4� iotal: _$___.__._.�19.5� 12�26�13 �9.41.31 Inv �: �Q�16 Rppr Code. 477131 Apprvd; Online CuSiolil'rl' �oNY THANk YOUt _ ,_ _ __ _ . _.__. .___ �._ .__.____-r __ _. � �- CITATION ,�, , State of Minnesota Ramsey District Court � ; City of '^.r, '°^'"�, ' V ' Citation# I� � i I IIIIII IIIII IIIII(IIII IIIII IIIII IIIII(IIII(IIII IIIII IIIII IIIII IIII IIII ! 620900206971 s2osoo2oss7� I � I DL Number State ; ❑MN ❑CDL � Name i First Middle last � ; Address— Street, Apt# �; City State Zip i � DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity � Vehicle License No. Plate Year State Make Type � Model Cs�lor �� '',�.. �'..�.� � ��t��:� ri'`���.,�'` ''�r��'..���"„�#� `'�'��?�`� ,�.. � ,� s,_s f . �'�'� �j .f � Date�of Offer�se .. Time of O.ffense ❑AccidenUCrash I �° " - ' '+� r "�`� � ❑Property ❑Injury ❑Fatal ❑PedesMan � Parking Meter Number Neighborhood Code ❑ Housing/Building Code N 0 � � � I ; ❑Booked Lfi�ar�c/Operate ❑Owner ❑Passenger ❑Driver O I Offense Location ,. � �N ..: �;<.�`�� `+�=t�..`s,t,...:;� 9 �-�•:��` N No 1 Offense ,,- <: • -- � , Statute/Ordinanse 0 ! � � . . � � ...��.���. �� �-.. ��� �a.F-�� �' �R.'..,� , I No 2 Offense Statute/Ordinance � � � ' NO 3 OfleflSe Statute/Ordinance I � i ❑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 (DOT) ❑Unsafe Conditions ❑School Zone ; � ❑Endangering Life & Properry ❑Work Zone ❑Commercial Veh. DOT# '• Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other j ' See back of citation for information on a in our fine. � PY 9Y � 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 ot 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. � i i i F � � 1 � � ' Officer(s)Name(s) j ,Officer No(s). =a;"��� CN# � �;�`"',;�:;�x� Citing Dept;#;";u<�w' } ! � I How Issued ❑In Person ❑Mailed C}Ceft at Scene � , i �__. DEFENDANT 2�y./�� s _ . ,. _ _ _ _� CITATIOIV ; ', State of Minnesota Ramsey District Court i City of °'` ; .•r � ; Citation# I IIIIII IIIII IIII�IIII)(IIII IIIII IIIII IIIII IIIII IIIII IIIII IIII)IIII IIII ' � 620900204859 620900204859 � ; , � � DL Number State , ❑MN ❑CDL � ` II Name � �n,; � First Middle Last � 't Address— Street, Apt# � i� City State Zip j� � � i � I DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity � -, , � Vehicle License No. Plate Year State Make Type Model Color ' � � r . ' - ! � .� R , � . � . .4n.-w� { i � Qate of Offense Time of Off.en e ❑AccidentlCrash �' ' • � � ❑Property ❑Injury ❑Fatal ❑Pedestrian � � ! Parking Meter Number Neighborhood Code ❑ Housing/Buiiding Code N ! ;i � � ❑Booked f�:°�''ark/Operate ❑Owner ❑Passenger ❑Driver � Offense Location '� � � ,' . , � r� �� �''♦" • i t� � � � r . , , �° N No 1 OffeflSe . "" � , Statute/Ordinance � ' � _- .. . -- i- ,: '�' / i � , . ... �� :�:. f .. s.%� t �W No 2 Offense scawceiom��a�ce � � No 3 Offense StatutelOrdinance � ❑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 ❑ Breath ❑ Blood ❑ Urine + ❑Hazardous Material (DO'i) ❑Unsafe Conditions ❑Schooi Zone j ❑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 j citation within 21 days from the date the citation is filed with the Court. � Please read the back of this citation carefully and respond. E � � ; I f i ! i � i ' Officer(s)Name(s) � � Officer No(s). CN# Citing Dept , � f How Issued � O In Person ❑Mailed O Left at Scene ' � � , i DEFENDANT ; i