Muhammad 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 municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,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 dces 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 1--�c�tl'1� 1 � Middle Initial � Last Name CY1 iY1 �M m ��'� �-,����v��
Company or Business Name
Are You an Insurance Company? Yes/ t�o If Yes,Claim Number? JAN 31 2�14
Street Address 2 ZZ�`-t 1-t�11�,r-�a�e A-c.�c°,
CITY CLERK
City `�t- � C�c4�.:1 State fYl (1 Zip Code �-�C��i 1�i
Daytime Phone(_) - Cell Phone(�L)7�1_-�Evening Telephone(_) -
Date of Accidend 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 of Saint Paul or its employees are involved and/or responsible for your damages.
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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 you need to include copies of all aqplicable 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 WII.L NOT be returned and become the property of the City. You aze 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 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—nlease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telerhone mbers: � �,,r��`� � �
l��i• 315 - Uv�)(r� �
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. t�V �fl
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�jP �tl'\N��i,`�,t' �"Sl't' ��- —Tdi�I��X`�.>(Y l `� z IA . r[�
Vehicle Claims—ulease complete this section ❑check box if this section does not anplv
Your Vehicle: Yeaz C�_Make�;,;�c 1L Model (��fld � �. ;r�c',E"�
License Plate Number � State rn"; Color t^(1(���:r.�l
Registered Owner � � '
Driver of Vehicle ' m
Area Damaged 'N ��
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 Q"check box if this section does not annlv
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
Cd Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this forni,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
Print the Name of the Person who Completed this Form: � �
Signature of Person Making the Claim:
Revised February 2011
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State of Minnesota Ramsey District(;ourt
C1TY OF SAINT PAUL
PARKING CITATION
C�tation No.: 620901390800
� - Caas No.:
SL Paul Police Department
VehicleLlcenseNumber: Z�5LCJ state:MN USA
Vehicle VIN:
Make:BUICK Madel� Color:MAROON
Typ�:pASSVEH
Ta6 Month: Tab Year:
Date of ORenss 01J14l2014 Time o/ORense 23:20
Statute/Ord ORsnae
161.03 Snow emergency parking restrictions
ORense Locatlon:
OAKLEY AV Intersectinp Street:PRIOR AV N .
��� 2nd Crose Stresk �
�. Offenae Gty:
SL Paul
Mstsr Number. Permit Zone: Sipns Vie:
� Chalk In: Chalk Out: Parketl: (HH:MM) Time Zone:
Unit:960
Officsr t:PEO D.Longbehn,Jr
Orticor Number:408505
Ofiicer2: ,
ORicer Number:
' Report defective meters by noon the nezt business day
Call(651)266-9776
To pay your 8ne by credit card,wait 5 business days and then call
(651)286-9202