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Donahue (2) NOTICE OF CLAIM rORM to the City of Saint Paul, Minnesota Mi�utesotu Sta�e Statute 466.05 stntes that "...every person...wl�n c/nims�Iamnges fi�on�ariy mu�iicipnlit��...slial!crui.re�o he���-e.scn�nc!to!he goi�erning budy o/�t/re muriicipa(ity wi[hiit /80 dcn�s nfter t/ie a/leged loss or injurv is discovered n notice stciti�ig fl�e linie,pince,a�td circumstcmces tlrereo/;nnd the mm�wtt of compensntinn or other relie�demnnded." Please complete this form in its entirety by clearly typing or printing your answer to each question. If mure space is needed,attach additional sheets. Please note that yuu 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 f'orm 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 ���� Middle Initial � Last Name��V�� y`��v v D Cn E�VE D Company or Business Name �$ 201� Are You an Insurance Company? Yes/No If Yes, Claim Number? Street Address � � V� V VV�Vr, V1�'��! iJ� CLERK City ����,�i State ��� � Zip Code � �� Daytime Phone ( �� ) �'� �ell Phone ( ) - Evening Telephone ( ) - Date of Accident/Injury or Date Discovered �2�,�(�'�I� � I� Time�_am/pm Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate w y or how you feel the ity of$aint Paul or its em loyees are involved andbr responsible for your damages. ' (�� C G� V�' ( �h�' � ti �i� �^'�,�, '�l V( � 'G � 1'L�!��7"I Z��G G'�V�,'U ,'( L� " �t ' C'�-- � L- n i� u�, c�w� �r�� o� ��v��`w �o�td�� w V c� , � � u v� � ���► v� � � � ^` '�' � � G� � ( j, �' '��1�Gf 'l,f G�� "!U ' 'L �l� � . 1 � � Z�"l;� 9 � C �v1� . �l t� �1 � � wr t�.��t � ��� �t,d !�`G r� C� ' �- ��� - 1� r�- �i�� � ` t W1 J V f�, �' ►�n �t b G��,UI [ � G� � vc�u-� �'1" u',I� vw � V �t vt " � � 'vEG ' � l�t� tN � V � �j � ��h;� �� rti�-� Please c eck the bo�(es)that mos 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 `�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 •�ou need to include copies of all apnlicable 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 WTLL 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 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 . . Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please comnlete 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 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 amoun[ ou are seeking in compensation pr what you would like the City to do to resolve this claim to your satisfaction. �'+1�. � �� �il�`Gl �l� �lG'�i��"� Vehicle Claims— lease com lete this section ❑ check box if this section does not a i Your Vehicle: Year ZULJ Make �7S1ti(�{,�1. Model �. �f; Y�k'�l�' License Plate Number State�Color ��� Registered Owner f��/ Vtli�'.� � n(( �I,j,�J Driver of Vehicle Area Damaged �3AVehicle: Year yGG'(� Make ��11:�1�UZ1�CiU� Model License Plate Number �3� Dt'rL State�I�Color P�1��� Driver of Vehicle (City Employee's Name) Area Damaged In,�ury Claims nlease comnlete this section ❑ check box if this section daes 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 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,yoit are stating tltat all information yoic ltave provided is tri�e and correct to the best of yoicr knowledge. Unsigned forrr�s will not be processed. II Submitting a false claim can result in prosecution. Date form was completed � —�--�'��� Print the Name of the Person who Completed this Form: 1����� —��� V }'�� � ' Signature of Person Making the Claim: _,��„I il 1 i � 1 `^-'��/��� / � Revised February 201 I i � . _ . ... . , � CIT � ATION � State of Minnesota Ramsey District Court - Ciry of ; Citation# IIIIIIIIIIIIIIIIIIII II IIIII IIIII IIIII IIIII IIIII IIIIIIIIII IIIII IIII IIII 620900205455 620900205455 ' DL Number State Name ❑MN �CDL First Middle Last � Address— Street, Apt# Ciry State I Zip DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity ( 1 Vehicle License No. Plate Year State Make Type Modei Color � Date of Offense 1 Time of Offense ❑AccidenUCrash � � , . . � . - ,. . ❑Pro � � peAy ❑Injury ❑Fatal O Pedestnan � Parking Meter Number Neighborhood Code ❑ Housing/Building Code N � ❑Booked ❑Park/Operate ❑Owner ❑Passenger ❑Driver � ' Offense Location � � ' � N � No 1 Offense Statute/Ordinance 0 � NO 2 Off2f1Se Statute/Ordinance 'p + No 3 Offense Statute/Ordinance v• � i O 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 j ❑Hazardous Material (D0� ❑Unsafe Conditions ❑School Zone ❑Endangering Life& Property ❑Work Zone ❑Commercial Veh. DOT# i 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 1 citation within 21 days from the date the citation is filed with the Court. + Please read the back of this citation carefully and respond. � 4 i I � ; � ! Officer(s)Name(s) � � Officer No(s). CN# Citing Dept � � How Issued ❑In Person ❑Mailed ❑Left at Scene � ( + � DEFENDANT � _ �i � - CITATION � State of Minnesota Ramsey District Court i City of , ' Citation# ' (IIIII IIIIIIII � : I IIIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII)IIIII III) 620900205453 s2o9oo2o545s � DL Number State + ❑MN ❑CDL � Name � � First Middle Last Address— Street, Apt# _ ', City State ZiP i DOB(mmldd/yyyy) Eyes Height Weight Sex Race Ethnicity � � , Vghicie License No. Plate Year State; Make Type Model Color � yF , Date of Offense Time of Offense ❑AcadenUCrash ❑Properry ❑Injury ❑Fatal O Pedestrian T V• Parking Meter Number Neighborhood Code ❑ Housing/Building Code N 0 � ' ❑Booked ❑ParklOperate ❑Owner ❑Passenger ❑Driver � � � Offense Location 0 � - . � �V ; N01 Offe11Se Statute/Ordinance 0 � � � � No 2 Offense Statute/Ordinance � ; w i � No 3 Offense StatutelOrdinance 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 (D0� ❑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 i Driver's License must be shown at one of the Violations Bureau locations listed on the back of this ', citation wiihin 21 days from the tlate the citation is filed with the Court. Please read the back of this citation carefully and respond. ; i � i � i � � Officer(s)Name(s) j Officer No(s). CN# Citing Dept � � How Issued ❑In Person ❑Mailed ❑Lett at Scene i i � DEFENDANT � i Saint Paul Police Impound Lot, 830 Qarge Channel Road, Vehicle Release Form Make: 05 HONDA License#: 781 KXY CN: 13272990 Invoice#: 24467 Date/Time Released: 12/26/2013 09:05 Tow Charge: $ 123.95 Released to:TOTO Storage Charge: $ 0.00 - ���N"-" Paid by: CREDIT CARD Admin Charge: $ 80.00 � Released by:AMANDA Tax: (7.625%) $ 15.55 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50 I will 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 5/2000 Signature s PfiUL mrounn �oT ff3t� BARt]E CHANNLL RU SA]NT PAUt.� MN. 551F17-295kf 651-266-5E42 Merchant IG: 84�1A6386149 Term ID: 6U173900NC�$00638U14�106 Sale � zzzzzzzz czz420 i UISR Entrv Method: Swiped �mount: � 219.54 r�X; $ 0,00 iotal: � 219.50 12�2oi13 10.42.20 � Inu a; ���4n�8 AApr Code; �6624p APArud: Online c„sc�����•� c�N, TI�ANK YOU!