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Branson RECEIVED NOTIC� OF CLAIM I�'OR1V��� t�i�e�ity of Saint Paul, Minnesota Miniresu�n St��e Stntnte 466.05 slotes tliat " ...every perso��ilt!)c7nii31S'�Inn��c.�m mtv m�nticipnlity...shall cnuse�o be pre.senter([o d�e governing bucfy<��'tlre municipnlity witltiit l80 duys after dte n(leged loss or injury is discovered n natice stntiilg the time,pince,nnd circumstances tliereof,and the amnunt of compensation or nther relref dem�nded." Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additionat 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. Yoi�will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer dependinb 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 �' !, ,_> /U ���Y1�� _� C� ,/ First Name � ��—` Middle Initial� � Last Name Company or Business Name Are You an Insurance Company? Yes/�� If Yes, Claim Number? < n ,,_-- Street Address �-�' � � � `n " � J� � � � S �� City ���-- State V "� �� Zip Code_�,�� � Daytime Phone ( ��)������ell Phone (�) � ;��-Evening Telephone�� )T��-.��j.,�-�-.--- � Date of�Accident/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 #�eel the City of Saint Paul or its employees are involved and/or esponsible for your damages.� �r'�j��`�_/� 1 _ �1�;- � . � __ S c> ��� _ �/�-� .. ., , . ��C�`� � _ �5-1- � ' ��� t ` � � S' _ � � I -, � - , - " � /� p ��y� -3 � i�� � �.�4�l� � ��i� 'c��c� P�c�ec�C� ox th�at mo�f c�o.e1y rep�`esent t e reaso for com��ag thik form: �,��( ��jC��� \ � ❑ My ve � e was damaged in an accident ❑ My vehicle was damaged dur�ng a tow���'��� ❑ ehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow`�cJx��C� y 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 ��� �` ��r w, In order to process your claim you need to include copies of all apnlicable 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 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 I+ailure to complete and return both pages will result in delay in the handling of your claim. All Claims—please comnlete this section �����_. Were there witnesses to the incident? Yes No Unkno�vn �' (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes N 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 o,f.Park or facility, clo�est landmark, etc. Please be as detailed s ossible. If necessary, attach a diagram. �"��.%1�'C �i� � ( d- �; r-s�c`�, Please indicate the amount you are se�l:ing in compensation or what yo would like he City to do to resolve this claim to ur satisfa�tion. v � � � �' C� P � ��i� " y��, _�� +U Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year '��Make � Model �U License Plate Number �-- ' � -`J /!� G �.( S �te�Color �'' — Registered Owner � � �vLL� �� � Driver of Vehicle � c_ — � Area Damaged � 'C' City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged In'ur Claims— lease com lete this section ❑ check box if this section does not a 1 How were you iniured? i� =� What part(s) of your body were injured? %l,��ty`� � 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 Emplo Address Telephone Check here if you are attaching moi•e pages to this claim form. Number of additional pages By signing this form,yoa� are stating tlzat ull inforrreation 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 f'orm was completed }� Print the Name of the Person who Completed�his Form: �1 fl��. �� �.� � 1%`L��� �,��G,�1'1 �("�; Y' . � � � Signature of Person Making the Claim: f �- _ °x—� . __,�--- �� --. Revised February 201 1 �frl(iPl�:., .,, �.,�..... ......... . �� is ..�,,��,�, .._, , . .,. . , .� :� �a• ��•Ir.r � . . ?i� ,��:��.l�l�y�i�1�F,,.t i4i,yi���l�/y/9�jh �7..8i�?"d56;'y,r,i��1�1�9e1��r (� 1i, c� . ' ;� � � I�'�ts+��i����� c:;ydib}�'� i�1111�h %e1:�u:u 'i��'Q`i -`;i��%/'\\����\h�l� I�i�'v'r�i r��b���i�� a��lrri��%/'��������i�l�l I�i�ri/.. � �� � �1�� �� ��i (i'� ��/i� ' ..s /� � 1�1�1 ���r�/��I���,` g���.'!�I=Il/l�jll'.,f�%�p1.�'w. +\ 1�I�I��j�1�fi�-/i �'`y�;�i /�� - ��\ �1111� �����\ ��1111� �// �` ��,�I�IN�. � �. �\ "'..1 cJ :�j�i� � �ii/ .�Il�llltii�i//ic'a��`���i���l�l��i�i•y!///'����.!i�l�l�l�l���,��/%/i�i\\����`. li��i�^�����\Z�d�ll�i�l�l%i �' \al�i�ii�1�Ii�//r-> > a il�i� O � .�� / \�. i b-'�//'.^., a h� i . �� ��ii � �� i . . � i . �.. �1%///-t�U�\ � ��iifif.,�e��, i�%�//�G/w?�,� � /� \��� �` 4�� �dA��j/ /� I f.��j�\�d���l��d///�i//i��."�,�h�,'�����ll�/i�1/�1-:\,��,ti.- '1// v�� �rr ��" ii�' � � � vc C� D i °V� ,�� ��Yi���l r_A :,. ��.r � ^ � _ � � _� _ � _ � � � �ll. `-�'A�_ - - M����F 1 , _ _ _ i\�\ � VEHICLE IDENTIFICATION NUMBER YEAR MAKE Y J MODEUBODY /TITLE NUMBER /�\\\ / � // , �.�����. - _ __ _ _ ^ =`_�`': "'�' KNDJT2A5XD7598886 13 KIA 4W SOU F1,59A0572 �;�" =��>;, ,.En;; ?.�,� ,�,.:�, ���ii DATE ISSUED ODOMETER TAX BASE CODE PLATE NUMBER CENTRAL OFFICE USE ONLY �IfN; _��'��� O6/10/13 31 �15175 09 109LRC %%%`" �; NEW 05/18/13 EXP 04 � ��� ;„ ;�, ;��i! "'`;, \��� �,`�,,.,, �v��u +y."';' `��:`\ FIRST SECURED PARTY DOB 1ST OWNER �:�;=' =:_= 05/18/13 51067 BRANSON VENUS MARIE _ ;;;�� 03164 MONTGOMERY JOHN WESLEY III ;�,�;� =;%�� w�� �».�� CAPITAL ONE AUTO FINANCE ?�:��� ��;�tz r•,,i "�'� 1228 BRADLEY ST '%'�>; �`���: - ;_`; _ ___ PO BOX 66�068 SAINT PAUL MN 55130-3506 _-- ' SACRAMENTO CA 95866 :; � !%i% TOTAL LIENS 1 ������������������������������������� ������������������������������������������������������������� '+�:"; �.,,, ;,.,, ��`�`, �°%� = Z " -3;i% ''``'' ; , , . . . -.- �e',� �,ii' ;n;:`: ���s�� FEDERAL AND STATE LF�WS REQUIRE THAT YOU STATE THE MILEAGE IN CONNECTION WITH TNE TRANSFER OF OWNERSHIP.MINNESOTA LAW REQUIRES THFlT YOU MFlKE A i��� ����v� DISCLOSURE ABOUT DAMAGE TO THE VEHICLE. A FALSE OR FRAUDULENT STATEMENT OF PURCHASE 6Y ANY PFRSON IS A GROSS MISDEMEANOR OR FELONY. i'% '��`V . . . .. . .. .. .... _._.—__._.. _. . ... .. . ... ... ._..._._. __._- __ ._.... .. ..... __... _ . _.../!� .�, �'[i ODOMETER DISCLOSURE STATEMENT. I(WE)CERTIFY THAT THE ODOMETER NOV'J ❑IS AC7UF�l MI(.l:_Fli;E _ - I�IFXCFFDSMF(,HANI(ALIIMI7SOFODOMLTLR � ��� �� REF��S _ (NO TENTHS)�41LFS AND TO THE BEST OF NIY ��S NOI�(1 UAL MIf tAFl.� WARNING ODOMETER DISCREPANCY �°6�.i�� �/�� KNOWLFDGF iHE ODOMETLR MILE.�GE , ��ti� ,('/ ___ ._._ .-�___ _ .._._ _ _ . 9.If C....__ .-.___ .._._.__.. -_- ..- ...._-_- _ ]ji ``�\� DAMAGE DISCLOSURE STATEMENT. TO THE BES7 pF MV KNOW�EDGE,THIS VEHI�LE�. ❑NAS 0 HAS NOT iGHEGK ONE)oJSTAINEO DAMAt;E W EXCFSS OF 80 PERCENT ACTtIAL(.;ASH VAL UL. ���P :�`\ i�/'!. y'-\ ASSIGNMENT I(WE)CERTIFY THAT THIS VEHICLE IS FREE FROM ALL SECURITY INTERESTS,WARRANT TITLE,AND ASSIGN THE REGISTRATION TAX AND VEHICLE TO =-' _ _ ,; \`'` �� ��r,� `f.�r - � � \t:?. ���i� SELLER�S PRINTED Nl�ME(S� DATE OF SALE BUYER'S PRINTED NAM��S� ��)}'sv.; t-�(�� iiY'i,S VAV�A� ijlA: :�\`\ 'i/,J_ `.�� SFLI F12�S ADDRESS DEALER:S LICENSE�# BUYER'S ADDRESS _ � SFLI.FR�S SIGNATURE(S� BUVER�S SIGNATURF(S� " � %ii'% APPLICATION FOR TITLE BY BUYER TRANSFEREE . MUST BE SUBMITTED WITHIN 10 DAYS Please Print �`���` „ -;��:;;, ��r ,,,;.,� i{ ��t � ;%;s ca��` ,•r;a ��� :stinnu i�;i� �uil Miuuii in i .� n iuh�iH �v�risuvn ��uc�NS�N�mn�i.r.i�� ��!�_" /� ��.n�� rvjr.�il�l f-nzil (rui.�n lwnuu i�niil�)rnium�i e ir��r,z,.F�snciNSr r,+ri:i51 __ �� 1'. ;�}�� ,���,� . VA�A� "i:i i �� .�• ❑rv co iNrvi�onr ;inrF ni•�:"ni 1�J�s� \��� IS THIS VEHICLE SUBJECT TO SECURITY AGREEMENT(S)? ❑NO ❑YES(IF YES,COMPLETE SECTION BELOW) J��' - FoHnnninuhnisi ioi�nr.iirs. �-� i �ir;,s i�i�i na.n rni i'.�Nnnn (ridN�n�nMr 1 oni r�rsr��.uimrv n��FFMFN i nTrnr n<<Mr�i��r[o r oi M PS2017 ,� '. � %�/J�%/�q srnit, i i j➢�\�a �`l"2 .�I1:1 F I 1 I�� t;llv �:)�. A )f%✓Jr i'c\�� I(WF l FI I .:. `�� � �IFYI(WFIAM(�REIC�FLEG�L�C,'E.HAVEPURCNFlSEDTHISVE.HICLESUBJECTTOLIENSSHOWNANDNOOTHEF2S.1(WF1F�7TESTBYT411STF2ANSACTIONTHAT7HISVEHICLEISANDYJIILCONI'INU�TC�PFINSII{ED �d�� �~\.�ia�� :�kl��(Jf'Cf:/�T�U U!'OI`J I I IE PU9LIC�TREE?5 FlND!'.IGIi`.M1'.4YS.ALL OF MV(OUR�DECLl+R�TIONS AFE TRUE AND C012RECT. _. . ,_. _ . _,_ , ..___ ._.... ._ _ : � "• 4 ....._ .._ ... . ._..... .. ........ .._.. _..... . . . .- . .- . ..... _. .. I MINNES(7TA .f�UNI'1 ClRO HFl '�IFltE� \r • i V�HEfEVE.iItIF I_KFFI � 1 j/r , ��1�.. ;:9 �S\h: �?��/ IMPORTANT-PlEASE READ ALL INFORMATION COLLECTED ON THIS APPLICATION IS RE�UIRED RV 1 AW AND IS USED TO IDENTIFV THE MOTOFi VEHICLE.FAILUHE TO PROVIDE REQUIHEU INFORMAiION MAV RESULT IN ��)� S��t\� J\��� DENIAL OF THE REUUESTED ACl ION.EXCEPT FOR CERTAIN USES PERMITTEO BV FEDEFAL AND Sl-A(E LAWS.PEFISONAL INFORMATION CONTAINED IN YOUR APPLICATION MAV NOT BE UI;CLOSED T()FlNVC7NF WIiHOUT j���f ����� VnUR FXPHESS(;nNSENT.VOU MAY EXPRESSLY CONSENT TO THE DISCLOSURE OF YOUR INFOR�IHTION BV WRITING THE FOLLOWING ADDRESS: %j�',-� �` �r e -=- MINNESOTA DEPARTMENT OF PUBLIC SAFETY =- ���� DRNEF AND VEHICLE SERVICES DIVISION ;\�;\. .s`�'� II I IIIIII IIIII I II I IIII II I I I'II II I I III 445 MINNESOTA STRE tivs dpamn.QOMINNESOTA 55 7 01-5 7 68 ���? %�;�// PHONE 651497-2126 T�Y 651-282-6555 �>I�ai �ti�� �i�! �'�`� PS2700-19 ��- 0 0 0 N 4� M � � � N J - � W j V � O O � � O � � v �ri O ui � C7 n c � r ao � N � N z � � � � � � � � � ll Q ll w C �' � w v °' °' �' � � � `� °' ° � rn O _ °� � c�s N � ` >, � ll L � U � � � V - � m > c� U � c � o c� �p c�a ' ..- � W � o I—� in a H cn c�n' t—� z � C � Q ' T � � O � Y I 0 � v � ~ �� � L � N � i � .� � �' � .-,. J � � O � J � � N v U _ i� o � = � � � cA U � � J � fl- � � � Z � � � � — O l Z � o � � � o. U 0 � � � � � • Q U O . "p p tn o N o�'�. > � � 3 s a } �I �._ 3 0 "' \ � p c � � � � o � a — � � ,..._. � O � Y � J U � .-� � U U N Q • LL! � � O N � � � � � � Z � � N � � � � p � F- � � � � w � � � � ? N � 0 � � N > � � � � c� a = o � � � Q o � � I } � � � � � � j � � c o � � O o co } ' � � J C � � •V � '� O � F- L Q a� �- � rn� � o � o- � '� U � p � 'tn "-" p � � � 0 W � �''� � � U � � � > � � � � � ~ � L � � N �. � c � c� � v� cn � � � � — ai � c� � c� � U L �., c� � � � � c� ZS cYa io —a�i � a� .,L.�., �3 � �c� c�C c c�a o O � � n g o o� a. a[ _ _ E cn � o o � �- v� -__ -r � CITATION ; State of Minnesota Ramsey District Court � City of T ;� . Citation# III�IIIIIIIIIIIIIIIIIIIIIII IIIII I�III IIIII IIIII I�II IIIII II � III IIII IIII 620900216403 620900216403 DL Number State ❑MN ❑CDL Name First Middle Last Address- Street, Apt# � City State Zip DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity Vehide License No. Plate Year State Make Type Model Color � �..T., ! ^y..-i r�! Ji.s�y�d y t` �',.t h_ .a.y�..+�� d :"� :..{ ) Date of Offense ' Time of Offense ,� ❑AccidenUCrash ' . � � � - � ��'� ' �' `�„�' ❑Property ❑In�ury ❑Fatal ❑Pedestrian Parking Meter Number Neighbor�ood Code ❑Housing/Building Code N ' 0 ❑Booked �7-f�ark/Operate ❑Owner ❑Passenger ❑Driver O Offense Location � ^..c!� � .�y`�:'\'``4"�' � ' ... � •- H � a:�._ No 1 Offense s�ac��eiord�o�,,�e. �,, � : ,� � � . p � . :�.r.; _+5�,.,: .i �. r�^' _ ,:.�,`w... ;5`. �r "'� f A � No 2 Offense Statute/Ordinance '�' O No 3 Offense Statute/Ordin�nce w ❑Speed 169.14(subd ); mph zone __ ❑No Seat Beit Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) AC Taken-AC: Test type: ❑ Refused ❑ Breath ❑ Blood ❑ Urine ❑Hazardous Material (DOT) ❑Unsafe Conditions ❑School Zone ❑Endangering Life & Property O Work Zone ❑Commercial Veh. DOT# Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other ! See back of citation for information on paying your fine. i if cited for No Prooi of Insurance or No Driver's License in Possession, Proof of Insurance and/or � Drivers License must be shown at one of the Violations Bureau locations listed on the back of this � citation within 21 days irom the date the citation is filed with the Court. Flease read the back of this citation carefully and respond. � s,. �Ay..= , e`�� �,,:j "�Prul�x. ���' .i`� M �� 1 .. � -N'�`... . ._.._ ..:.+. ..._ �. , . . :f, . F � Officer(s)Name(s) Officer No(s). , • CN# ! ., ;; F Citing Dept . �.i How Issued ❑In Person ❑Mailed ' OLeft at Scene ` ' � i � !1'i::�=i�i�3Q�i'��, I T