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N4TICE UF CLAIM FORM to the �i�y of Saint Paul, Min����ta
CITY C�E
Minnesota State Stuture d66.OS states ahnt"...er•ery person...who claims ges cvey municipalit►�...shall cause to be presenred to zhP
governing body of tize rnunicipalin wi.thin 18(1 days after the alEeged loss or zn.jury is discovered a notice stating the airne,place,and
circurnstances ttaereof,and tlie wnouns of compensation or other relief demanded."
Please complete this form m its entirety by cleariy typing or printmg yonr answer to each qnestion. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to ciarify answers,so provide as
much information as necessary to ezplain yowr claim,and the amount of compensation being requested. Yon will receive a
written acl�owledgem�nt once yanr form as received. TLe proces.s can take np to tea wee�or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If somethmg does not apply,write`N/A'.
SEND COMPI�ETED FORM AND OTHER DOC[TMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �7��a,�_ Middle Initial�Last Name
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address ��� �� f Q�"i.fl�C�� �"�' � �� v- � —
City `'�� �i � State �� Zip Code SC �
Daytime Phone(�_I_)�1 So�(Cell Phone(�f(_)�-�°�Evening Telephone(�)�-=Zz�
Date of Accideirtl Injury or Date Discover�l�r �o� O/?� Time 1f/- � am I m�
Please state,in detail,what occurred(happened), and why you are submitting a claim.Please indicate why or how yrou
feel the City of Saint Paul or its e�playees ar invol ed and/or responsible f�your damages. �J
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Please check the box(es)that most closely regresent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
❑ jviy vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
�My velucle was unc�ngfully 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��ueed to include coaies of all aualicab�e 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 bec�me 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 estimates if the damage exceeds$500.00;or the actual bills
and/or receipts far the repairs;detailed list of damaged items
O Injury claims:medical bills,receipts
O Photographs aze always welcome to document and suppart your claim but will not be returned.
Page 1 of 2—Ple�e complete and ref�rn both PagQS of Cla�i Form
Failure to complete and retarn both pag�es will re,sult in delay in the handling of your claim.
All Claims—nlease comqlete this section
Were there wirnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? ��:�s-' No Unknown (circle)
If yes,what department or agency? Case#or regort#
Where did the accident or injury take place? Provide street adckess,cross street,intersec�tion,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
Please indicate the amount ou are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. _�� c1
Vehicle Claims— lease com lete this secNon ❑check box if this section does not a 1
Your Vehicle: Year Make Model �
License late Number4�,��^_��I-4?_ State�,�..Coior '
Registered Owner
Driver of Vehicle t''
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle{City Employee's Name)
Area Damaged
Injurv Claims ulease comolete this s�tion ❑check box if this section dces not annlv
How were you injured?
What part(s)af 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
'�Check here�'you are atta°ng more pages to this claim farm. Number of additional pages �' .
By signing this forin,you are statirag that all information you have provided is true and correct to the best
of your knowledge. Unsigned form� will not be processed.
� �^�
Subm�itting a false claim can result in prosecution. Date form was completed�.� ,� �'�C� ,a�
Print the Name of the Person who Completed this Form: �'n ��� �
Signature of Person Making the Claim:
Revised Febcuary 2011
Saint Paui Police Department P� 1 of5
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Trme of Report
�
13258611 12/04/2013 16:59:00
Primary offense:
AUTO THEFT-AUTOMOBILE
Primary Repating Officer. Yager, Avery V Name of IocatioNbusiness:
Primary squad: 26$ �ocetion of incident:�AMES AV 8�TORONTO
Secondary repating otficer. ST PAUL, MN 55104
Approver. CaS@y, Brian
o►st�cr. Central Date&time ofoccurrence: 12/04/2013 06:30:00 ta
Site: � 12/04/2013 14:30:00
Arrest made: -
Secondary offense:
Police OfFrcerAssaulted or Injured: Police OfficerAssisted Suicide:
Crime Scene Processed:
OFFENSE DETAILS
AUTO THEFT-AUTOMOBILE
Attempt Only: Appears to be Gang Re/ated:
Crime.Scene Method 8 Point of Entry
Ty�� Public domain Force used: Hid Inside:
Descrip6on: V6hICle Point of entry:
Method.'
�ctims
Dougherty, Graham Robert
NAMES
Suspect
UNKNOWN
Nicknames or Aliases
Nick Name:
A/ias:
AKA First Name: AKA Last Name:
Details
Sex: Re�e: ��8= Resident Status:
Hispanic: Age: from to
SP301588F78460F
P� 2 of 5
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Refeience CN Date and Time of Report
13258611 12/04/2013 16:59:00
Primary offense:
AUTO THEFT-AUTOMOBILE
Phones
Home: CelL• Contact:
W�: Fa�c: Pager.
Employment
Occupation: Employer.
lderrtification
SSN: Lioense or ID#.� License State:
Physical Description
US: ���
Height: to Build: Hair Length: Hair Color.
WeighL to Skin: Facial Hair. Hair Type:
Teeth: Eye Cobr. 81�TYPe�
Ofiender Information
Airested: Pursuit ergaged: V'�oleted Restraining Onier.
DUf: Resistance encountered:
Condi6on:
Taken to health care facility: Medicat re/ease obtained:
Victim Dougherty, Graham Robert
203 VIRGINIA ST Apt G
ST PAUL, MN 55104
Nicknames or Alfases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Defai/s
�� Race: White DOB: g/9/1 g76 Resident status:
sex: Male
Hispanic: Age: 37 trom to
Phones
H�: ���. Contact: 651-955-7508
Watc Fa�c: P��
Employment
Occupation: Employer.
SP301568F76460F
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Saint Paui Police Department Page a �5
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Refeience CN Date and Time of Report
13258611 12/04/2013 16:59:00
Primary offense:
AUTO THEFT-AUTOMOBILE
PROPERTY
fTEM#1
rype of�oss: Stolen ��af��� 12/4/2013 ���co�: James Av/Toranto
Owner. pougherty, Graham Date Recovered: Location Recove�d:
Model#: Qliantity: Serial#:
Article Type/Item: Other property / Vehicle rotai�aiue:
Desaiption:
7umed in at Locker ID#: Lab exams:
VEHICLE INFORMATION (Property)
Status Description
;''` Status: Stolen �ioenseno.: g27B1-�Z Year. �ggs
Towed: No
state: MN ryae� Sedan
Lock stafus
Year. 12/2013 �b� Blue
��� Doors unlodced: V.L IV.: �S� 4
lgnition unlocked: Make: HOflda Transmission:
Trvnk unlocked: �e�� CIVIC ShiR Position:
Keys in vehide: Np Mileage:
Insurance d owner infom�ation Vehlcle contents 6 driver
Insurance co.: Keys ln vehicle: NO
Uenholder. OwneraHowed someone to
use vehide:
Lease Company:
Amounf Owed: $Q sto�n�moa. Other
Registered owner. DOUghelty, Grdham Robert ���O"e��=
Drivers license no.: Personal property in vehide:
. Vehicle Damage
NO APPARENT DAMAGE
Participants:
Person Type: Name: Address: Phone:
Suspect
SP301588F76460F
P89e 5 of 5
Saint Paul Police Department
ORIGINAL OFFENSE 1 INCIDENT REPORT
Complaint Number Reference CN Date arM Time of Report
� 13258611 12/04/2013 16:59:00
Primary offense:
AUTO THEFT-AUTOMOBILE
Victim Dougherty, Graham Robert 203 VIRGtNiA ST Apt G
ST PAUL, MN 55104
NARRATIVE
No ICC for 1900.
On 12/04/2013, at1500 hrs, SQD 268 (Ofc. Yager), was sent to 203�rginia St, on a report of an auto theft.
Upon arrival, I met with the victim and R/O, GRAHAM ROBERT DOUGHERTY (DOB: 09/09/1976, 203
VIRGINIA ST#G, C: 651-955-7508), who stated he parked his vehicle, Blue 1996 Honda Civic, MN plate:
827BHZ at the intersection of James Av/Toronto this moming approximately 0630 hrs, as he arrived for work.
DOUGHERTY stated he got off approximately 1430 hrs, that's when he found his car missing from the location
of where he parked it.
DOUGHERTY stated his vehicle was stolen previously about a month ago.
�` The vehicle was not towed per DATA..
, .
DOUGHERTY has no suspect information.
There are no abnormal characteristics on the vehicle.
I contacted DATA and had the vehicle entered as a stolen.
I cleared without further incident.
PUBLIC NARRATIVE
On 12/04/2013, at1500 hrs, SQD 268 was sent to 203 Virginia St, on a report of an auto theft. A report was
written.
SP301568F76460F
Page 1 of 1
Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
`13258611 12/07/2013 11:11:00
Primary offense:
AUTO THEFT-AUTOMOBILE
Primary Reportingr Offrcer. Radke, ThO�t'12S W Name of locatron/business:
Primaiy squad: Loca6on of incident�qMES AV&TORONTO
Secondaryr�patingoff'�cer. ST PAUL, MN 55104
Approver.
o�strict. Central oare a r;me oroccur►ence: �2/p4/2013 06:30:00 ro
5;�. 12/0412013 14:30:00
Mest made:
Secondary oflense:
Polioe OiFicer Assau/ted or Inju�d: Police Offroer Assisted Suirade:
Crime Scene Processed:
NARRATIVE
• On 12-07-2013 I reviewed the Original Report and there were no suspects or further evidence to proceed
with the investigation at this time.
The vehicle was recovered on 12-06-2013 at the Snow Lot at 1129 Cathlin Street. The vehicle was towed
from the Snow Emergency from the area of Grace/Osceola/Webster. There were no suspects arrested or
identified at that time.
Pended due to the lack of solvability factors at this time.
PUBLIC NARRATIVE
SP301568F76480F
_ Saint Paul Police Department Pa9e 1 of 2
SUPPLEMENTAL OFFENSE / INCIDENT REP4RT
Complaint Number Reference CN Date and Time of Report
13258611 12/07/2013 00:26:00
Primary offense:
AUTO THEFT-AUTOMOBILE
Primary Reporting Officer. Krumgant,Vladimir A n►ame ot�ocat►onmus�ness:
pri��y,sG,�: �� locationofincident 1129 CATHLIN ST
Secondary�eportingofficer.� ST PAUL, MN 55108
,approver. Labarre, James
o;sma:Westem Date 8 time of occurrence: 12/07/2013 19:01:00 to
Site: 12/07/2013 19:01:00
Arrest made:
Secondary offense:
Police Officer Assaulted or lnjured: PoFoe Offioer Assisted Suicide:
Crime Scene Processed:
OFFENSE DETAILS
AUTO THEFT-AUTOMOBILE
Attempt Only: Appears to be Gang Related:
SOLVABILITY FACTORS
Suspect can be ldentified: By�
Photos Taken: Stolen Property Tiaceable:
Evidence Tumed In: Property Tumed In:
Related Incident:
Lab . __ .
, Biological Analysis: Fingerprrnts Taken:
Narcotic Analysis: Items Fingerprinted:
Lab Comments:
,
�Participants: .
Person T Name: Address: Phone:
YPe�
NARRATIVE
NO ICC AVAILABLE
On 12/06/2013 at 1901 hours, Squad 166 (Krumgant) responded to 1129 Cathlin St (Snow Impound Lot) for a
recovered stolen vehicle that was towed during a snow emergency.
' SP301588F76460F
Saint Paul Police Department P� 2 °f2
� SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Complaint Number Refeience CN Date and Time of Report
13258611 . 12/07/2013 00:26:00
Primary offense:
AUTO THEFT-AUTOMOBILE
I located a 1996 Honda Civic (MN/LIC 827BHZ) in the parking lot and noticed that it had damage to the front
bumper and the front driver's side window was rolled down approxima#ely and inch, allowing snow to enter.
The keys were not with the vehicle.
I was told by the impound lot staff that the vehicle was located in the area of Grace/Osceola/Webster(ref
parking tag#620900172254).
I completed the towed vehicle report and contacted the R/O notifying them that the vehicle was located.
,
I contacted DATA and entered the vehicle as a recovered stolen.
1 processed the scene with negative results.
''�_
PUBLIC NARRATIVE
Supplemental report.
,�
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