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Gevretsadik NOTIC� OF CLAIM I'ORM to the City of Saint Paul, Minnesota Mburesota Stcue Stutute 466.05 stntes that "...eve�v perso�i...who clnims damnges from a��v nru�ticipciliry...slrnU cnu.se tn be prescn[nd[u the goi�erning hocl�'uJ�die n�unicipality wi�hi�t l80 duys nfter tl�e ulle�ed loss or injury is cliscovered u norice sta�iir��he tinre,place.uird ci�-cums7uitces tltereof,nnd t/ie mm�unt of compensntinn or other relicf demnncled.'• Please complete this form in its entirety by clearly typing or printing your answer to each question. It'more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to clarif'y answers,so provide us much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your i'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. lf something does nol apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 1� � -�� First Name 1' )1 c� �� Middle Initial � Last Name �b��1 K Company or Business Name RECEIVED Are You an Insurance Company? Yes/� If Yes, Claim Number? ioN 2 4 2014 Street Address ,°� � �v�� X 1 "�, � v r1"T'v n LERK City C,�� State M1�' Zip Code�v � Daytime Phone (�) o�-��Cell Phone (C S 1) �`�-�`'135 Evening Telephone ( ) - Date of Accident/lnjury or Date Discovered � � ' � � ' �3 Time I i� am� �m 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. � � �� . ,� � 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 durinb 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 you need to include copies of all anplicable documents. For the claims types listed below, please be sure to include the documents indicated or it will delay [he 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 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 retumed. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both page�will result in delay in the handling of your claim. All Claims—please comnlete this section Were there witnesses to the incident`? es No Unknown (circle) Provide their names, addresses and telephone numbers: ��--t�.�x��2S�" (~�a,ip�'Ylo��-�C `1 '(�—r6`�t�b 4s�y \°�� m1a,w�-��C'�}.f,�u.0 iM N' �ci o°� 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, eic. Please be as detailed as possible. If necessary, attach a diagram. � � �i��n1 a�� S� C+ V�1 �-�-�-c.ZS ��'tY�^^ �� rv.St �c.� S,`�e Please indicate the amount you are seeking in compensation or what you would lihe the City to do to resolve this claim to your satisfaction. :i w�-. 51�:��G� --tro �d' ��1_°l.• �o �Q�xv� Vehicle Claims— lease com lete this section check box if this section does not a I Your Vehicle: Year 1 °1 � �Make Model L� 17 .S L � License Plate Number ' � State�► �'Color �; \��°J`� Registered Owner '1�1 ;� �-t C-� �` �s��`?� Driver of Vehicle �i i�SSg L--�>rd`�'�� Area Damaged ,�:;� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged � Iniurv Claims—please complete this section �check box if this section does not �tpply 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 iniss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Na�ne of your Employer: Address Telephone ❑ Check here if you are attaching moi•e pages to this claim form. Number of additional pages By signing this form,yozc are stating tltat ull information you lzave provided is trice ared correct to the best of your knowledge. Unsigned forms will not be processed. Siebmitting a false claim can result in prosecution. Date f'orm was completed Print the Name of the Person who Completed this Form: ��1;c�� -�_�-��1� Signature of'Person Making the Claim: -�zl 1 � Revised February 201 I f cn � � o o Q- cn � - - �p v � o � Cn `� � o a� � � w � �. � m a�_ m � a� iu �• 3 3 � ��`< = � m a m m � �' � m su � � c� c sv � � � .� � � 70 m N � � < m n. � `� � �� C° � m � m � o � cc� � c� Q- n n � u' � m o Q 3 Q � � � n ,� 7D o �p D c � � o o' o � � m � D p O � C O � � � � � — � � 3 0� 0 a ?:� m C� p m Z c) C� cp � o � � o � y n. (D � � � < m �. � � � � n� � v, o �. � � mo � i '� = I � cQ -a � 3ao 00 0 � o � � m - m w � � � 7� I � � su ?<° Q- u'' r' r � v v, � � �D r« rv o � � � o � w � O �o � Q � � a�i � m �' m o° � � N � N � �- � O y �n o Q g' o c� -< � O � � -�• Q- C�O W � Z � �, c� 'v N � (Q O Q � N p�' a � cD W yo � � Q � m a�, � ° � � c� � cn � � ° z �p m �~ m � D - N �l D Z o m c u�i a � o � � O � � � x � ° � � P- 0 W � n �� o ..� O � � � � � � `Q � c� �p C� � t�» tQ � N cQ � .,. m .. � .. � � r �p m c � � � � � � � � 1 3 � . � 1 Q 1 � O Q N � � . � � T O O O � O O � � 0 m � � r N O �"' � � 1 � N � O � O O . _. _ _ __ . � i I CITATION � � State of Minnesota Ramsey District Court � t City of - - � Citation# I IIIIII(I�I IIIII IIII)IIII)IIIII(IIII IIIII IIIIIIIIIIIIIII IIIII(III IIII ' � 620900203854 620900203854 � � DL Number State � ❑MN ❑CDL i �' Name � First Middle Last ( , Address— Street, Apt# ! ( City State Zip ; I DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity � Vehide License No. Plate Year State Make Type Model Color, � ( " _ , Date of Offense , Time of Offense ❑AcadenUCrash # � ❑Property ❑Injury ❑Fatal ❑Pedestnan � � Parking Meter Number Neighbofiood Code ❑ HousinglBuilding Code N � � �� ❑Booked ❑Park/Operate ❑Owner ❑Passenger ❑Driver O � Offense Location„* , � ` .� . i.,r � ` �. . . � � � No 1 Offense s�amceiordinance � i , ,: �, � � � NO 2 �ff2f1S21� Statute/Ordinance � � �!+ i No 3 Offense StatutelOrdinance � � ', ! ! ❑Speed 169.14(subd ): mph zone E ❑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 s ❑Endangering Life& Property ❑Work Zone ❑Commercial Veh. DOT# � Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other i See back of citation for information on paying your fine. � If citetl for No Proof of Insurance or No Dri�r's License in Possession, Proof of Insurance and/or j Driver's License must be shown at one of th Violations Bureau locations listed on the back of this ! � citation within 21 tlays from th�date the citation is filed with the Court. j Please read the back of this citation carefully and respond. � ' i i i Officer(s) Name(s) � Officer No(s). CN# Citing.Qept ; How lssued ❑In Person ❑Mailed O Left at Scene � { � � � � � DEFENDANT j