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Flores Cordero NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the governing body of the municipaliry within 180 days after the alleged loss ar injury is discovered a notice stating the rime,place,and circumstances thereof,and the amount of compensation or other relief 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 form 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 �I�u�� Middle Initial�Last Name ��Y�� 1 /�' 1�o Company or Business Name �� Are You an Insurance Company? Yes No If Yes, Claim Number? 1e,N 31 2�14 Street Address �l/�/�� U� C►i(.i n n hoc��l� a �� l �''TY CLERK City �� State �/V Zip Code �� Daytime Phone(�)�- .3� Cell Phone(�)g��-�CZ Evening Telephone( ) - Date of Accident/Injury or Date Discovered � 1� Time �� a /pm 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. .S _ ;� � S; r 1kJC � �s�-�han � �� -�- �e.k hcrd , o �0 Y w � "GC r" r C� � C - l�&- 8� ' ;k d � a tt, c �' ' �V-i n a •,�rti,h � 3 '"` 0 � a+� � 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 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 vou 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 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 biIls 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 complete this section Were there witnesses to the incident? Yes No Unknow (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. �y�V1� I'�t1(L_�'lU�(A �iQ, Please indicate the amo nt you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. �7 I�' s� Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year 'ZO�Ii Make �i. Model �r`V i��G License Plate Number ��/Sr I��F� State� 11�Color Registered Owner OW � S r� �� r �- OC,�! Driver of Vehicle ZS v 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 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 � (provide date(s)) When did you miss work. � Name of your Employer. Address Telephone �Check here if you are attaclung more pages to this claim form. Number of additional pages�. By signing this form,you are stating that all 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 form was completed_.�Zq/� � Print the Name of the Person who Completed t's Form: �/��Y �`�P �' 5ignature of Person Making the Claim: ��ti v(/�— Revised February 2011 ��- 0 0 0 ST PflUL If�UIlm LUT 830 BARGE CHANNEL RD � ('' �n SAINT PAUL, f�l. 55107-2450 L 651-26&-5642 � r � LL � Nerchant ID: 2006380144 � Terv ID: 0017340600800638819465 � � � (n N � � J Sale � XXX�XXX4�J N � rn o °o � �°n o �°n � � � r � 00 � N � N VISA =Entrv Method; S�iped . � z iotal; � 219.50 " � � � � � � � a � w 12�05�13 .__ 0�;57,11 > � � --. � �,; w Inv �: 00000Z R�pr Code, 030958 � � °' � � � � � A�rvd: Online o � � � � � � � .� � � r� U � c � o � U � m Custoaer Caav � ?� � � X � Z (II W THANK YOU! � � �— Cn Q F— Cn fn F— Z Q — � M = � (C r- ¢ _ � Z � � � � � U N U `� �' ° �- � w >. o � � � o a�'i o m -0 — L., J m } N n � •3 � d � v II � s � m a U Z � � , � o � � � o �; Q p a�i � c � 3 � -a } � ca -- c -J c �n � 3 ° � O � L � o � � � o � � ,� � � °Q I w � � � -a �s � E � � � � � � — a� '� z cn � c°v > � �n � o � � F- , � � � � � � av� � 2 � � . o � �. c N Q W � O N � � > � N Q' � J � L (� L (4 a � � � � a� 3 Q o a� � } � U a�i O U 2 � � a p >, o .� ai � a o � o � � � � � U � o o � O z �, �- o � � � � o o a o � � � � o � � �L � on- � � -°c Q w d � � � U m � aUi > � � ° a� � �- � - o � >, c .� co � � � � � � a rn � � , � Y �' a�i � a�i a� .0 >,c � � E � a c '� ca i6 a� ca a� � 3 � cv c� c � o O °_' - cn � o � a. � _ _ � cn -a o o a F- in ,1Ct,l�� C�� Iit��..�i� �i ,nJ� �P��'��(�_ -�1��b D @ 3�� 12� i� I�3 � Q 5 D��/ i� .�'� �!I d� a✓� � n��-h�-1�ii�� a►� l�a �,,�, - S��r�,S�Y �u�ll ��ve � a I�A � � �C� C�� ' _ � �i�Y �.Y" 0''��` � _ -L' �„' . I �� V' � `.b-D � " ��.�:� t55� � '�°` P ��,, �:�d.- i o � --� fi��s I�v�� P � ♦ ' ' . � �- ` �ITATION � State of Minnesota Ramsey District Court '" City of Citation# I�H��uNI��J�l(�� IIIIII 11111 1111 INII 11 S209fl0'�74710 s209Q0174710 DL Number State ❑MN ❑CDL Name Frst Middle last Address- Street,Apt# Ciiy State Zp DOB(mm/dd/yyyy) Eyes Height Weight Sex Race EthniCity Veh�1Q License No. Plate Year State, Make Type . Model Cotor t,� :� ��., '� ��_ � z - ;� '� - , : ._ - Date of Offense,� Time of Otfense : ❑Acadent/Crash ' � �. - �� — j�} f °-, :,,=-^ ❑Property ❑Injury ❑Fatal ❑Pedestrian � Parking Meter Number Neighborhood Code ❑Housing/Building Code N . � ❑Booked ❑EPack/Operate ❑Owner ❑Passenger ❑Driver O Offense Location � � � � No 1 Offense � �� ► £�`i.e�'� �� , 03 �. No 2 Offense �°'��0r�"�'� � � No 3 Offensle staart�obinance , �. � ❑Speed 169.14(subd ): mph zone ❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) AC Taken-AC: T�st 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 Drivers License in Possession, Proof of Insurance andlor � Drivers License rrnrst be shown at one of the Violatlons Bureau locations listed on the back of this citation within 21 days ftom the date the citation is filed with the Court. � Please read the back of this citation carefulty and respond. � ' � Officer(s)Name(s) , - Officer No(s). •`�r ' . �. ,�:. fs CN# �= � '`�,.�,,.f Citing Dept��:� �� i How Issued ❑In Person ❑Mailed ft at Scene - � � DEFENDANT � � , ,...,. � tV � -,� ' --, � ; �� , � � � � ' � '' . �. . — — — — — — —— _ — — —.� _ — — r�� ia )P��i��ic3�l��'� t i �� ,� e�� -: ��.Sk s�Sk � - �� S��''� � � � � ► � � � � - � , _