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Malcolm RECEIVED FEB 12 2�14 C�ITY CLERK NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso Minnesota State Statute 466.05 states that"...every person...who c•larms damages from any municipality...sliall 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 anzount of compensation or odier 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 J c,�i� a n n e� Middle Initial J Last Name J,la.l C� �I1'� Company or Business Name Are You an Insurance Company? Yes No If Yes,Claim Number? � Street Address � (� C� f"1�10 /�l/�P1 ,(e, City S r. ��(/I � State �� Zip Code 5 5�6 3 Daytime Phone ( ) - Cell Phone(�12)� 3345Evening Telephone( ) - Date of Accidend Injury or Date Discovered ��/4 Time � 6� �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. l i.t)QS ��,l#C�d r� �. % s n u �� :;�-� �'Qi�, � �� o h'ld �- !�6 u -�.. V I h" d� d'b � 1CG 41^- j � � Yt�7it - 1�--• J �Lul �l/L1 �� .d �Du I o� ��s.�. �fmJ��- �,��h�,t . Please check the box(es)that most closely represent the re son for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow O 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 conies of all applicable documents. For the claims types listed below,please be sure to includel 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 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 � Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims: two repair estirriates 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 comulete 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. S�vU GJri�a r4�K.. 5vJ Co r ner Uf Cv►no d �/�'c�-o rr G` 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. (�OS1' Of �f0 W ihG � � 2/�1 . �0 Vehicle Claims—please complete this section ❑check box if this section does not applv Your Vehicle: Year 2012 Make 1-�01'1dGl Model �i f S�o(r License Plate Number 49�[ L 12 A1 State.M�Color Ll1��C. Registered Owner c)i�l�C�f�n� �►�lal C�(rr� Driver of Vehicle J i.�li Ctir�ne J✓�u I�Calr 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 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 ! I ❑ Check here if you are attaching more pages to this claim form. Number of additional pages ' By signing this form,you are stating that all infor»zation 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: � .�t� f�ahn e. �a�C(��7'Y�- Signature of Person Making the Claim: �"l I�� Revised February 2011 Saint Paul Police Impound Lot, 830 Barge Channei Road, Vehicle Release Form Make: 12 HONDA License#: 499LRN CN: 14019188 Invoice #: 27694 DatelTime Released: 01/31/2014 07:46 Tow Charge: $ 123.95 Released to: TOTO Storage Charge: $ 0.00 Paid by: CREDIT CARD Admin Charge: $ 80.00 Released by: ELISE Tax: (7.625%) $ 15.55 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50 I will check the vehicle for damage or any other problems that may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00 Saint Paul Police Department. I acknowledge I will report damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50 on this form prior to leaving the impound lot. Damage and/or other problem: Police Report made: Yes_No_ IF Yes, CN , If NO, Why? TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT Signature 5i2000 *620900521115* Page 1 of 1 INCIDENT INFORMATION REPORT 2/�2/2014 STATE OF MINNESOTA COUNTY OF RAMSEY DISTRICT COURT INCIDENT AND CITATION INFORMATION INCIDENT ID PAYMENT PLAN CITATION NUMBER 2766476 620900521115 DEFENDANT NAME JULIANNE JOYCE MALCOLM ADDRESS 860 COMO AVE ST PAUL MN 55103 DEFENDANT INFORMATION DATE OF BIRTH 6/17/1962 GENDER FEMALE HEIGHT 5 Feet 2 Inches EYE COLOR BLUE WEIGHT 148 Lbs. DL NUMBER B372051212112 DL STATE MN RACE HISPANIC (Y/N) OFFENSE INFORMATION DATE/TIME 01/31/2014 01:25 DIVISION RAMSEY COUNTY LOCATION 860 COMO AV COMMUNITY ST PAUL AGENCY ST. PAUL POLICE DEPARTMENT METER ISSUING METHOD LEFT AT SCENE OFFICER 1 585005 CN OFFICER 2 NBRHOOD VEHICLE INFORMATION PLATE 499LRN MAKE HONDA STATE MN MODEL FIT PLATE YEAR COLOR WHITE VEH TYPE PASSENGER VEHICLE VIN JHMGE8H58CC037717 VEH YEAR RESPONSIBLE PARTY ID METHOD NONE CHARGE INFORMATION STATUTE/ STATUS REASON JURISDICTION ORDINANCE DESCRIPTION OPEN STPAUL 161.03 Snow emergency parking restrictions ORIGINAL FEE INFORMATION AMOUNT DUE $40 FINE 40.00 $40 FINE 40.00 LAW LIB PARKING 3.00 LAW LIB PARKING 3.00 Srchrg-2nd District 1.00 Srchrg-2nd District 1.00 Srchrg-Parking 2009 12.00 Srchrg-Parking 2009 12.00 GRAND TOTAL 56.00 GRAND TOTAL 56.00 OFFICERS COMMENTS CN14-019-188 PARKED ON SNOW EMERGENCY. BOTHSIDES OF STREET NO PARKING STARTING AT 2100. . PUBLIC WORKS FORMAN STATED COMO WAS NOT PLOWED DURUNG NIGHT PLOW