Harris, Ryan R�C�IVED
, � F�B 24 2�;4
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes�t� CLERK
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall 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 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 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 � Middle Initial M Last Name �1°`�r r'-S
_ Company or B�siness ame
Are You an Insurance Company? Yes/No If Yes, Claim Number?
Street Address ���� �°�����-1 /�3 �
City �'h��`��i S State /_ �� Zip Code SS�T D$
Daytime Phone( (Z)��_Cell Phone((o� )�X�S-�665 Evening Telephone�Z) �-�b�
Date of Accidend Injury or Date Discovered � � Time a /pm
Please state,in detail, what occurred(happened), and why you are submitting a claim. Please ind' ate why or how you
feel the City of Saint Paul or i s emplo ees are involved and/or responsible for your damages. �H E�t� '�^�`LS
� �,� 9✓� �l1ar> �L'„ � - �v r-, a� •
�- a � � � d t_ -
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
�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 ou need include co ies of all a licable 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 andlor 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 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—ulease 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? es No Unknown (circle)
If yes, what department or agency?�J�'• 1��� po �� Case#or report# C lJ�l' f�f Oo� v7 7
Where did the accident or injury take place? Provide street address,cross street, intersection, name of�ark or facility,
closest landmark,etc. Please be as etailed as possible. If necessary,attach a diagram. T4�a- •�r �n (o
CI I6�1 ni�tr��� Jc. • St. t�aKi MN 510�1 L Q i�ro•� �1�Nrr�
Please indicate the amoun�,y��rQe sre7.ew�ng in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year 91 Make n Model Gc o r
License Plate Number 2— C-y State M�Color '��cJ' M
Registered Owner a.ti �rr.`
Driver of Vehicle �r1 •ti -}{arr��S
Area Damaged �
Ciry Vehicle: Year� Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name) �
Area Damaged
Iniurv Claims—Alease complete this section ,�'check box if this section does not apqlv
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 Emgloyer:
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 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 �� �
Print the Name of the Person who Completed this Fo r^�1 ��r�
Signature of Person Making the Claim:
Revised Februazy 2011
` St. Paul Police Department for
Ramsey District Court
RECEIPT
Date/Time: 01116/2014 19:40 Invoice#: 25717
Vehicle Plate: 732DVG/MN
Payor: Locatian Paid: lmpound Snow Lot �
�
Citation: Amount:
090Q200783 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CREDIT CARD
NB COPY
Saint Paul Police Impound Lot, 830 Barge Chanr�el Road, Vehicle Release Form
Make:97 HONDA License#:73� CN: 14008439 Invoice#: 25717 �
Date/Time Refeased:01l�6/201419;4 Tow Charge: $ 123.95
Released to: � Starage Charge: $ 15.d0
Paid by: CREDIT CARD
; Admin Charge: $ 80.00
'�
ReleasEd by: LAM `z� Tax:{7.625°l0} $ 15.55 �
F
1,the undersigned,have recovered the vehicle described abave. Subtotaf: $ 234.50 `;
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 !will'report
damage and/or any ather problems to the Impound�ot staff Tota!Charges: $ 234.50
on this form prior to leaving the impound lot.
Damage and/or other problem: `'
�
{
Police Report made:Yes_No_IF Yes> CN , If NO,Whyf?
T�PROTECT YC7UR RIGHTS REPORT ANY PRjQBL�MS1L7At�AGE BEFORE LEAVlNG"THE L�T f
}
5/2000
Signeture
3.
Saint Paul Police Department pa9e � °'�
t�RIG1N L C)FFEMS / 1NCIDENT REP RT �
Com�laint Number Reference CtV Dafe and 7'ime of 1?eparf
��000077 0�lo�l20�� c��:2s:ao
Primary offense:
AUTO TNEFT-AUTOM�'JSILE
Primary Reporting Oflicer: (y1C81�1ti�, Michae! G Narrte of lcacationlDusiness:
�r;n:ary squar�: ��� Locatron o�tncidant� ��p1 UNIVERSiTY AV Vtil
Secoradary reportiny oflrcer. S`T" PAUL, MN 55�C14
t�n�rover.� ����rre, James
�istrr�t:�/�(�g�gm Date&time o�occurrence: 1213112413 21:00:04��
Site: 01101/2Q14 01:49:00
Arrest made:
Secondery offense:
Potrce�ffr"cerAssaultsd ar 1nJured: Potice Officar Assistad Suioida:
Crime Scene Processed.�
flFFENSE DETAILS
AUTd THEFT-AUTOMOBELE
Atternpf Onty: Appears ta be Gang Refated.
Victims
Harris, Ryan Mitcheii
NAMES
Suspect
UNKNOWN �
idtcknsmes c�r Ali�ses
Nick Nar»e:
Atias'
AKA First tVame: AKR Lest tVsme:
I
Det2ils '
Sex. Race. DOB: Resrdefaf Status:
H+spanic: Age: from ta
Phones
Homa: Cell: Cantact:
Work: Fax; Pager.
SP583095C279DBC
Saint Paul Police Departm�nt Pa�e � °��
R! NA OF ENSE / I CID NT EP RT
Compfain[1Vumber t?efercnca C1V Dafe and Trme af Report
14fl00fJ77 �!11C711�01� 02:�8;QQ
Primary offense:
AUTO THEFT-AUTOlV1t7BILE
Empfoyment
Occup�#ion: �m�fr�yer:
ldenftRcafion
SSN.• License or ID#: _ license State:
Physicat Descriptlon
tIS' MefriC:
Neight to Burid: Nair Cength.� Marr Color.
Weight� ta Skin: Facia!Hair.� Nair Type:
Teefh� Eye Co(or.� Btood Type:
Offender Informattan
Arrested: Pursuit engaged: Yio/afed Restraining Order.
DUt: Resistance encnurztered�
-, Condition:
Taken to heafth care tacilify: Medical retease obtained:
Victim Harris, Ryan Mitchel!
280Q HARRIET AV SE
MPGS, MN 554�8
Nicknames ar Aliases
Nick Name:
Alias:
AKR Flrst Nan7e: AKA Last Name;
t7etails
Sex: ����
_ Rsca: White DOe: 7l4t1983 i�esidenr Status:
tFispanic.� Age: 3Q trom to
Phanes
Nome: Cefl: Gorrfact: $12-$05-46$5
Wark: Fex; , Fager.'
Empioyment
Occupation: Employsr:
Identifrcarion
SSN: Ltc�nse or fD#: Llcense Stafe:
SP5�3096C2'9C?BC
Saint Paul Palice Department P�g� � of5
� N�� / �NC�d T
Carnplarnt Number Reference CN Date and Time of Reporf
14Q00077 �110112014 02:28:OQ
Paimary offensa:
AUTO THEFT-AUTC�M�BIL
Physicat Descriptfon
US: I�jp _ Mefric. NO
Neight: to 8uitd: Harriength: HairColor:
Weight: to Skin: Facrai N�rr. Hair Type:
Teefh: Eya Cotor.• 8tood Ty�e.•
Viciim i»formatfon
TvpB individual can rdenriry artender. Np �virtf�q to�ress cnarges: No
Gondifion:
Taken#o heaRh care facrtiry: Np Medics!redease obtarraed: Np
SflLVABILITY FACT4RS
Si�spect can be fdentifred: By:
Photos 7aken: Stolen Property Traceabie:
Evidence Turned In: Property Turned!n:
Retated lncident:
tab
Biologicai AnaJysis: Fingerprints Taken:
Narcotic Anafysis: ttems Fingerprintsd:
Lab Comments
PROPERTY I
1TEA.+1#1
f�y�a a�Loss Stolen t�a�e of�oss: 111/2014 Locatfon Lost: 1�C11 Ut11V@t'Sit�j
owner: Harris, Ryan Mitchell Date Recoversd: Locafion Recavered;
Modet#; Quantity: Seriat#:
I
Articte Typat ttem. Qth�C�JrO�?eft}� ! V2hICf8 Tote!vatue:
Descript+on: �Otlf18 aCCdfC�
Furned in at: Locker 1{�#: Lab exams:
sFSSaassc:z?a�»�
Saint Paul Police Department Pa9e 4 of�
t� � �NSE r rNCia
Complainf Number Reference CN Uste and Time of Report
1�000077 01 f01 i2014 02:28:04
Primary offense:
AUTO THEFT-AUTC}MC}BiLE
VEHICLE INFORMATION (Property}
Status Descriptioa
Status: Stolen License no.: 732DVG Year. �gg7
rowed.• �o Sta#e: (�(y ryne� Sedan
tackstatus Year: ?1�p�4 ��r: Tan
poors untocked: V.t.N.: 1 HGCD563GVA020305 000rs: 4
lgnition unlocked: 1vleke" NOfltl2 Transmissior�;
Trunk unlocked: Model: ACCORQ Shi�t Position:
Keys in vshicie: Np Mi#sage: �55,000
tnsurance&ownerinformatfan VehTcle contents&driver
Insuranoe co.: PROGRESSIVE Keys rn vehicte: �p
Lienholder Owner aflowed someone to �j�
uss vehicle:
Lease Company:
Rmo�nt Owed: $4 Stoten Mefhod: Q�#�e�
Registered owner. Has't'is, Ryan Mitc�rell Theft Coverage:
Drivers license no.� Persona!propert�in vehicte: rpjgC ClOthBS
Vehicle Damage
DENT BY DRIVERS SIQE€�C3ORGREEN FRONT BUMPER
ldentityfng characfertstics
GREEN FRC3NT BUMPERREAR BlKE RACK
Participants:
Person Type: Name: Address: Phane;
Suspect
Victim Harris, Ryan Nlitchell 800 HARRIET AV SE
PLS, MN 554C78
NARRATIVE
No ICC Sq 1098
Sq 112 McAlpine sent to 1�{}1 University on a report of an auta theft. (Jn arrival I spoke with the
victimlowner, Harris, Ryan Mi�chell fl70483, ph 6128054665, who told me that h� parked his vehicle behind the
Turt Club at approx 210� hrs. He returned at approx Q145 hrs and found that the vehicle was gone.
Harris did not allow anyone else to use his vehicle and had the keys with him.
SP5930�5C279CJ0C
Saint Paul Po�ice Department P��� � °f�
+�}RIGII��►L. �JFFENSE / NGI NT REP RT
Gcrmptaint Numbsr Reference CN Dste and Tirrre of Reparf
��0000�� a�to�l�a�4 a�:�s:oa
Prirnery affense.
AUTO TH�FT-AUTtJNIOBILE
Persana6 items in t3�� vehic(e were misc ciothirtg and a $5t}gift card.
The vehicle, Mn Lic 732-C}VG, is a 1997 Honda Accord 4 d�or, tan, wi#h a green front bumper and a rear
bike rack.
Ch 5 nc�tifiied.
No suspect info.
PUBLIC NARRATlVE
On fl1-01-14 at Q149 hrs, Sq 112 CvlcAipins sent to 16Q1 University on a report of an auto theft. No suspect infa.
SP583095C279QBC
)c'�Ill� pc'�I,I� A�ICB ���3r�i�l1'l��lt pa9e 1 of 1
SUPPLEMENTAL OFFENSE l 1NGIDE T REPOR
CQmptaint 1Vumber }Z$ter'ence CN Da#e and Tlme of Report
��.0000�7 o�E�s12o�� �5:5a.�o
f'r�mary offense:
AUT{� THEFT-AUTQ {�BIL
Primary Reporii�ig O�cer: StriCkk�nd, Tyft�ti�T tVame of loostian/trusiness:
Primarysqusd: LocationatraFCident: �$Q� (�C�{�1JERSITYAVW
Secand�ry reportrng o�`icer°: ST PAU L, MN 551 Q4
Approver:
plstrpct•�i�/g�$��°� Date&time of occurrence: 1213112f�13 21:QO:tICI;�
Sita: 0110 i/2�14 01:45�0 _
Arrest made:
3ecandary offense:
Police Offioer Assaulted or tnjured: Police Officer Assistad Sur"cide�
Crrme Scene Processad:
NARRATIVE
On 1/1512014, St. Paul stolen, license#732 DVG was recavered at snow lot at 1129 Cathiin. The veh�c6e had
been towed from 1606 Edmund. No ather in#o about vehicle or tawed info.
PUBLIC NARRATIVE
SP583085C279DBC