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J.� b � 7�A'�d�J�ij. - �- � ��. --- i� . � ._ �,� -_ � _- ___ __ __ . ._ __-�'�� s�� .��xv_��j�';c__ �._ �i__zrr�-j_,��._�?��,j_ �.�I1__ � _ _-___ __ ____ � d'�/ _ --___:,�-�,��,�___�s,�--�a _�►--��%��__��-v�:�� _�_�.,�. ��r�_—__ _____ _ .�i�s �,_�� /v� ,��_ �� _r��l-/ . ��-�«�►�{��__�`.. ___._ . _ _ _. �.___ __� _ _ _ _ __;��a��- Ti`��`��_�,..��__o�%_�%��,�.5'_ _ _ ____ __ ��-- o -�.w� a _ �r �i� -�'_ �,� �� -_ �,�-o��jiii►:a_.�_ ___ __ ___ __ _ _ �i y s`��`� S'�I�,�� ,� �f� 9`�'�� , � /l � � _ �,�'v,z �j��__i:��--o�,-�a� _ .. �-� _��,�.�_ �.�j j�_./��3�_��_J-�- _.______._. _ __.___ __..__ _ __ _ ._. .._ - __ ____ _ __Y ..s��-- - - ��r�iv �r ___ _ � __.��. J�io_.�� _� . �, _ �� / q, �y_y� ��_ _� _..._. � m. __._ _ _� �_ - --__ _ __ ___ ��.,��.�-��z��%o='%'�o�at��a��3'��'r�',�--�-v--�'a�- �-- _ _____ _______. _ __ � � - --��T�- - -y ___-____ � __ .. _ ____.________ .__.. ��uso.lJ� l`�'- ��_"��7_�'"�i/jTp� � . �,� � � �/ . • . . , , � . . . ,. , . , . . . • > , , . . � 4, • . . , , , , ' . . . , • . �� _ _ - -_ _ 1�1ti�� _ � � . .. .� . _.�� RECEIVED F�B 12 2�14 CITY CLERK 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 govenzing body of the municipaliry 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 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 ,��f'tv�tti[ Middle Initial��Last Name .Li�r/t�r�� Company or Business Name Are You an Insurance Company? Yes,�N�o If Yes, Claim Number? Street Address �GD Cer�se �d� City .� �,tu/ State 1��t/ Zip Code �3`/Q3 Daytime Phone(GS�)8�-.f�Cell Phone(iS� )��- S/y7 Evening Telephone( ) $aM� Date of Accidend Injury or Date Discovered ��3/�/$/ Time /�ao 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�� n�s.�s 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 C71 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 $�5/00.00;or the actual bills andlor receipts for the repairs W 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 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 amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction.�'/rit e / Toa�iKa ttpo�.�1��s Vehicle Claims—please complete this section C�check box if this section does not avnlv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle 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 avplv How were you injured? What part(s)of your body were injured? Have you soughC 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 fo►m,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 ��`��Sl Print the Name of the Person who Comple d is Form: �fl kl�T,G✓N�/�+I<i, � Signature of Person Making the Claim: Revised February 2011 r State of Minnesota Ramsey District�ourt CITY OF SAINT PAUL . ! . III � ��, _ I ,PARKING CITATION � I cic.c�on No.: 620900521114 � t C�u No.: St.Paut Potice Department V�hIclsLicsnssNumb�r: 564EGN saa:MN USA V�hlcle VIN: reaka:HONDA Modd: Color:RED Typ��PASSVEH �Tab Month: T�b Y�ar. . � ��te ofOR.c.;:.e J;;S ii[u'Iw � Tims o/Off�nss 01:20 St�tuts;Otd OBsn:e 161.03 8now emergency parking restrictlons . �Ofl�nss Locatl•,n: ;360 COMC AV Int�n�ctlnp Str��t. I1n.�ss Strest rOf►snss Clty: ��:O.t.P�W � �iMeter Numbsr: Psrmit Zons: Sipne Vls: Chalk In: Chdk Out: Park�d: (HH:MM) 71ms Zonr. Unit:971 �nc•r�:PEO N.Rosenberg ofticer Numbsn 585005 )ftic�r 2: . 6ffic�r Numbsr: Report defecttve meters by noon the next business day Call(651)266•9778 To pay your Me by credlt card,watt 5 business days and then call (851)288-9202 citsd for No Proof of Ins�rance or No Drivere Lieenes in Posaeasian,Proof c�Flneurencs andlor � -ivsrt licens�ahould be shown In one of the Violatlons Bunau Locatlons listed below within �business days of ths vlolatlon. To pay your citation onlins: www.�ndwsbe�courts_.state.m_n.us For addRional Intorm�tlon or to��ry your Bns by ulephcne usinp a credit urd, �fli: (661)266�820Y. Pl��se have your cRdlon number and crodk c�rd�vailabl�. � . - � - Mall p�ymeMs to: R�msey Didrict CouR Trd11c Violatlons Buruu . 16 W�st K�Ilopp Boul�v�rtl-Room 130 St.Paul,MN 661 02-1 81 9 MaNe checks paysbls to: Ramssy District Court (A chrrp�of up to f30.00 wlll b��n�s��d on dl nturnsd ch�ck�) '�/lol�tlom Bunw Lacatlont � St.Pwl Court Suburbra CouR -Lsw Enforc�msnt Centsr � . 16 W.Kellopp Blvd.RM 730 2060 WhIU B�v hv�. 126 Grow 3tn�t St.Paul,MN 66102 Maplswood,MN 66109 St.Paul,MN 66701 Ofic�Hours:8:00 A.M.-4:30 P.M. Mond�y-Frid�y(Excludin�Holla�yo) Hssrinp 011lcers:8y appointmsM oNy-cell(861 j-266-9202 Payment and Penaltles ,(you wish to ple�d puilty for th�o}1sns�(s)on th�nv�n�dd�a`ths citation,you must do so Hithin 30 days from ths date!hs citation is fllsd wKh the Couk.It is your rseponaibllity to present your payment n a timely manner.Pltas�allow 6 busin�ts dayt for proc�sslnp.A t6.00 late!es in addsd to ell unpaidlf��e bdencee.ARsr40 d�ye from the dsts ths citetlon ie flled with che Court additiond dslinquent fees may be addsd to�II unp�id fins amounts. Additional penelties may include:1)rsferral to ths Departmsnt of Public Safsty for driver's , � licrnes susp�nsion,2)vnat w�rrant isswd,md/or 9)r�brrd to a eoll�ctions�p�ncy. 'ith�o}►ensa is a p�tty misdsms�nor,hilur�to�pD��r will b�eon�idsrsd a pl�a o!puilty and Naivsr to.f-�e rip�:tc tr!a!!aniese the feiWro to sppe�r is dwlo circumstancee bsyond the person'n control(M.S.169.91 J. ApPBdI �o plead not puilty,or to plead yuilty end oRsr an sxplanatl�n� 1)AR�r 6 business days,cali 661-2665202 to conflrm thet the cRation has be�n flled wRh the court. 2)If th�citatlon has b�en filsd,request�h��rinp oRlc�r�ppolntrisnt. � � Sairit Paul �c��ice lr��pQUnc� L�ot, 830 RargE Ghar:r�el i�oad, Vehicle Release Form Make: 09 HONDA L.icense i�: 564 EGN CN: 14fl s 9188 In�ioice �: 27695 Date/Tirr;e Released: 41/'31/2C14 0':44 Tow Charge: $ i 23.95 Released to:TOTO Storage Charge: $ 4•0fl Paid by: CRFDII" CARD Admin Charge: $ 80.00 Reiea�ed by= ELISE Tax� (7.625%) $ i 5.55 I,the undersigned,have recovered the vehicie described above. Subtotal: $ 219.50 l wiii check the vehicle�or damage or any othe� probiems that may have occurred while this vehicle was ir. the custody of the Service Charge: $ 0.00 Saint Paul I'oiice Department. ! acknowledge I wil� report damage and/or any other problems to the Impaund Lot staff Total Charges: $ 219.50 on ihis (orm pric�r to leav�ng the impound lot. Damage and/or other prob!em: .----- --------------._ _---------- ----- ---------------------------- ._ —__--_----------------------------- � Police Report made: Yes____No---.- IF Yes, GN--- ---- --------, If NO, Why? ------- ----------- TQ PRQTE�T__Y.OUR_RIC�FiTS RE�(ZT ANY F?FsOBLEMSL.A._M�1GE BEFORE LEAV�NG._.T_HE LOT 5/7U00 - Signature.-------- --- _ --- ----- ---- --- ---------