Mosner RECEIVED
; � - F�B 24 2�14
� NOTICE OF CLAIM FORM to the City of Saint Paul, Minri��CTt� CLERK
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 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 e�lain 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��n ��i�� Middle Initial J Last Name �GSI'}�;r'
Company or Business Name
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address ���' �m�nd}��C-
City �t' pO"v� State ��n n���L��`' Zip Code SS \O`-1
Daytime Phone( ) - Ce11 Phone( T e 3),;iH� -S�►ti�o Evening Telephone(_) -
Date of Accidend Injury or Date Discovered �• d0•�G1�1 Time � �v� �Jm pm
Please state,in detail,what occuned(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.On �-he h,yhi- c,�
t1'�C_ S ft0'� L YYICY'c4tYlCa�_� Mi,'�cj tY1l.A C��.� �KL�(Yl �cl mv n c� ci c-rri, ��,ova t iitc'_.\o
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n,�\ -�^Cr �.�.� c.�s b 1-c CY-e-t�d �nd -�x�r�l «+ ��.oo�-�m.
�{�t-er t�1e. S�c�% �YYIc_'�t��cC�e,u Nte� ��rn�, QL i�'•o� �tm r�'�nd 1��Z:(� C;X�7�r'tc�-_
Please check the box(es)that most closely represent the reason for completing this form: �
❑ My vehicle was damaged in an accident i ❑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 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 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
0 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 aze always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please cornplete 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-please complete 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 re'solve this claim
to your satisfaction.
Vehicle Claims-please comnlete this section ❑check box if this section does not applv
Your Vehicle: Year �o(X; Make 'PeN�ZA� Model (s,P-�N Q �`^
License Plate Number �-iC'�t� r'�PP StateN� Color ��LK-
Registered Owner Np.A-t-� 10�Y1�
Driver of Vehicle �'��'V 1N1l:SN�'�
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-nlease comnlete this section ❑check box if this section does not applv
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
�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 infornzation 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 a • • �`C�'�
Print the Name of the Person who Completed this Form: 1r�N��` V�10SH E �
Signature of Person Making the Claim: � '
Revised February 2011
�-�� .�r �
� CITATION � `� �,
_ State of Minnesota I IIIIIIIIIIIIIIII IIIIIIIIIIIIIII IIIII�IIIIIIIIIIIIIIIII��IIII IIII IH�
citation#:
62�9��222989 620900222989
• County Name: �''r�� Sequential Citations_of_
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� Identification: ❑DL ❑DVS eb ❑Photo ID ❑FP ❑Other
DL Number MN ❑CDL ❑State
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� Name: First Middle Last Suffix
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' Address—Street,Apt#
� City State Zip
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DOB(mmlddlyy) Height Weight Eyes Gender O
❑Juvenile Court Parent or Guardian's Name: ❑Same Child'S �
� Offense. Circle One: address as Race
iJTR,JPO,DEL Address: Juvenile �
Ve .Li .No. Plate Year St�aryte ' Make Style ❑16+pass. Cplor ',�' N
� ..�- � �'✓� i`�hi �ii .-:'.{�.t$��`> /�['1�'. ..-�'�w,� - \• .
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Date of ens � ime of se= ❑AccidenUGYash �
� ,�.,. � : �` �''��� ❑Pro e ❑In'u ❑Fatal ❑Pedesfian �
❑Urisafe co diti s Endangering Life or Property' ❑Commercial Vehicle �
� Weather: `CouR appearence required if checked DOT#
I
j . #Pounds overweight:
i ❑Hazardous Material DO
❑Driver ❑Owner p Passenger ❑Operate ❑Parked ❑Booked
o�e,pse o tio /� � �„; � r� f*� Circie One:�,j�yF�ountylTownshiplOther
--•�*��� t3 .���� '� ��'� ` Of: '�. !
i OHens�+ ' Chan�e Descr tion�,�� Statute/ inance �'3 ,,,� ❑3rd PM,M
E �" �����,,�4""����• � � -� � violation GM
Offense Change Description Statute/Ordinance ❑3rd PM,M
� violation GM
� Offense Change Description Statute/Ordinance ❑3rd PM,M
violation GM
Offense Change Description StatutelOrdinance ❑3rd PM,M
violation GM
❑Speed Minn.Stat.§169.14(subd. ) mph Zone PM,M ❑3rd in 12 months
❑No proof of Insurance Minn.Stat.§169.791(subd. ) M,GM
❑No Seat BeN Use Minn.St�t.§169.686.1(a) PM
AC Taken-AIC: Test Type: ❑Refused ❑ Breath ❑Blood ❑Urine
` If this is a payable citation,you must pay the amount owed or schedule an
� appearance within 30 days from the date the citation was issued.
See the back of this citation for more information.
Officer(s)Name(s) : "°�: Officer No(s) r""�"' Prosecutor
�_. „a.�.��-�,•�°_, ��
Controlling Agency(CAG) How Issued Date Issued
MN062b900 ,� � In Person ❑ Mailed ' 'Left at Scene
A enc Name: •`'- �' �' � �.% �4� � '.
9 Y ' �>�t c:N/IC e i f..'i °
Version:2013.1 Y �
I DEFENDANT
Saint Paul Police Impound Lot, 830 Barge Channel Road, vehicle Release Form
Make: 00 PONTIAC License#: 909BPP CN: 14033708 Invoice#: 29193 �
Date/Time Released: 02/21/2014 15:17 Tow Charge: $ 123.95 \
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: LARRY Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicie described above. Subtotal: $ 219.50
1 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 s�2000
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