Vang, Dao NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota SJate Stutute 466.05 states that "...every persctn...wlio dai�rrs dumnges fro�n�ir�y murticipa/iry...sfta/f cm.i.se!o be��resef�ted to the
governing boc(Y q�tlte muniripa/iry x�it/�i�T 180 derys nfter t/te a//eged lo.ss or injurv is discoverec!a�iotic e statirtg�he einte,p/nce,unrl
circeun.rta�rces tlrerc:of,and die nmount of conipensatio�l or o1{rer relref demanded.•'
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 f'orm 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 pa�es 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 e:� Middle Initial Last Name R�C�I�IED
Company or Business Name J�N 2 4 2014
Are You an Insurance Company? Yes/ o If Yes, Claim Number? r i Tv r�i �Q K
Street Address � �� ���'l ��
City State �,1�i � Zip Code � C� �
Daytime Phone ( ) - Cell Phone (�) `f0-S(3ZEvening Telephone( ) -
Date of Accident/ Injury or Date Discovered �� ��� ��`� Time 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 o Saint Paul r its ployees are involved and/or respqnsible for your damages.
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Please check the box(es)th�{t most clo ely r p ese�the�`ea on for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a t o w
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
Q�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 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 W[LL 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 Phocographs 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—ptease 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 enforcement called? Yes No Unknown (circle)
If yes, what department or agency? ( �u,� Case#or report#
°!i I -fo rcpm--1-
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 diagra�n.
Please indicate the amount you are s el:in i�com ensation or what you would like the City to do to resolve this claim
to your tisfaction. � 3 '� �
'� m m�e u t.�
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Zea2 Make � Model � �l �
License Plate Num r °IOP��I�T�_ State Z olor��J
Registered Owner � c �
Driver of Vehicle a
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
IniurV Claims �lease complete this section ❑ check box if this section does not applv
How were you injured?
What part(s)oi'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 t/tat all information you have provided is true and correct to the best
of yoicr knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date f'orm was completed �"2`���
Print the Name of the Person who Complete thi o m: � cs-
Signature of Person Making the Claim:
Revised February 201 I
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CITATION � �
State of Minnesota Ramsey District Court
^ ��l,�? ✓' �.
City of �f �` ' IIIII IIIII IIIII IIIII Illl llii
Citation# IIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIII
IIIIIIII
620900206587 s2o9oazos�s�
DL Number State
❑MN ❑CDL
Name
Flrst Middle Last
Address—Street,Apt#
Ci1y State Zip
DOB(mm/ddlyyyy) Eyes Height Weight Sex Race Ethnicity
,
.�
� Vehic/le License N : Platej Year {Sta�e • �elake T Model � Co�Or��` " /?
.. •�V��� �r�''��v� l ��� +��F�t £""�4�..+j ��� ���� '^"��F�:�� �. }�'f± .
�. F 7n4a..r.
� D t@ ofi 0{{°n Y Tiroe of_gffe��", ❑Aa�denUCrash �
�F i..�'y�4�. :�?� ,��. p p��h' ❑Injury ❑Fatal ❑Pedestrian
. t
Parking'Meter Number Neighbofiood Code ❑HousinglBuilding Code O
�` perate ❑Owner ❑Passenger ❑Driver �
❑Booked O
{�
Offense Locatio ---� t 1 -� � r�� �;;;�. N
�� ��.. ���� � ,, �; ��:�.. �
- s�anrte�o�a�n , �.-�, �
No 1 Offens�"��'�1 �.�`t���"�?�t:`t.. ��.=� � � �
statulelordinance �
No 2 Offense ; �
s�n��o�d��
No 3 Offense
❑Speed 169.14(subd )� mPh ❑No Proof of Insurance 169.791(2)
❑No Seat Belt Use 169.686.1(a)
AC Taken—AC: Test type: ❑ Refused ❑ Breath ❑ Blood ❑ Urine
❑Hazardous Material (DO'n ❑Unsafe Conditions �School Zone
❑Endangering Life& Property ❑Work Zone ❑Commercial Veh. DOT#
kIdentification: ❑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 lnsurance andlor
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 Cour[.
� Please read the back of this citation carefully and respond.
Officer(s)Name(s) . .,:E_ �
�,,.
Officer No(s). �';,�. ,�"�"',?' CN# �;,��, ��} .,,:�f' Citing Dept.�__ ���. +��./
c` - t `RatScene
Howlssued ❑InPerson ❑Mailed � _ -
DEFENDANT- '
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