Vang, Chee RECEIVED
MAR 0 6 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, M'�x�e�+o�ERK
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 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 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 does not apply,write`N/A'.
SEND COMPLETED FORM AND O�THER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name C �1 �-�- Middle Initial 1� Last Name ✓�'� � �
Company or Business Name
Are You an Insurance Company? Yes/;No) If Yes,Cllaim Number?
Street Address � �'� ��'� �' �n r�'S � �}'� � L
City S`;- - ��%�'z�� i _State � N Zip Code �S � U�-;
Daytime Phone ( ) - Cell Phone (��()L�L�- �'�'�%' Evening Telephone ( ) -
Date of Accidend Injury or Date Discovered � ��� � ' �i Time �S ��� C� am/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 << r`
n ��; n+- � _:�; e c � -� ' e �� ^ a
C"/l� �C" _ i� p_ 'r � r�c:� ' i � .� ' � ��� � �
v
I
C � T ��l�—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 venicie was damageci oy a pothole or condition of Ihe sireet C My venicle was da:nag�c�y a p'=a�✓
� 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 j���• „ppd 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 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 est�mates 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 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 complete this section -- 1
Were there witnesses to the incident? Yes �N�' 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 stteet address,cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible, If necessary, attach a dia ram. C�S �7�'m��s
.� �e # � �� - ��U � l�� �'1�t-�' C �.✓) 5��P ���� n' c n�.+M 1z�T St1'�t-_
Please indicate the amount you are seeking in compensation or what you would like the City to do to resol,ue this claim
to your satisfaction. `��� 1�. �;Z� °- i'C i M Y3�t r��N��t , ��l' �I- c�v�_�7 �-, 1�'e PS ,
Vehicle Claims-please complete this section ❑ che�k box if this section does not annlv
Your Vehicle: Year ��� Make fl-�r/ « Model H-�cv��%�
License Plate Number qS�L�r�C�- State 1�1 t�► Color ���� ✓1
Registered Owner��,i�i� � ��r<'t �� `�
Driver of Vehicle I-� � �'<� �1 � _
Area Damaged � '
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims-please complete this section C�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 information you have provided is true and correct to the best '�,
of your knowledge. Unsigned forms will not be processed. 'I
Submitting a false claim can result in prosecution. Date form was completed 3�N i �v�
Print the Name of the Person who Completed this Form• h � ��� � (
. , / � � �
Signature of Person Making the Claim: �' ' �
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Revised February 2011
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' CITATION � � :
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State of Minnesota I IIIIII IIIII IIIII IIIII IIII)IIIII IIIII IIII)IIIII IIIII(IIII IIII)IIII�II
Citation#:
C2a900223030 620900223030
County Name: Sequential Citations_of_
Identification�: ❑DL ❑�DVS Web ❑Photo ID ❑FP ❑Other
DL Number MN ❑CDL ❑State
Name: First Middle Last Suffix
Address—Street,Apt# �
I
City State Zip � �
DOB(mm/ddlyy) Height Weight Eyes Gender O �
� �
❑Juvenile Court Parent or Guardian's Name: ❑Same Child's � �
Offense. Circle One: address as Race Q
JTR,JPO,DEL Address: Juvenile �
Ve .�.No. Plate Year State Make Style ❑16+pass. Color �
; ;.# _<,� . ., -; .> '< t� �.
Ji-� .�S W
Da of Offense Time of�Offense ❑AccidenVCrash Q
❑Pro e ❑In'u ❑Fatal ❑Pedestrian �
❑Unsafe conditions ❑Endangering Life or Property" ❑Commercial Vehicle O
Weather: 'Court appearance required if checked DOT#
#Paunds overweight:
❑Hazardous Material DOT
❑Dnver ❑Owner ❑Passenger ❑Operate p.Ba�ked ❑Booked
Offense Location Circle One; City(,�ounty(Township/Other
. �_ , �, ; . Of: i ; '< �
Offense Change Description StatutelOrdinance ❑ 3rd PM,M
violation GM
� Offense Change Descriptiod 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
i
, ❑No proof of Insurance Minn.Stat.§169.791(subd. ) M,GM
�No Seat Belt Use Minn.Stat.§169.686.1(a) PM
� AC Taken—AC: 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.
�f See the back of this citation for more information.
i
Officer(s)Name(s) : Officer No(s) ,_; � Prosecutor
', Controlling Agency(CAG) ' How Issued Date Issued
MN0620900 ❑ In Person ❑ Mailed 0 teR at Scene
Agency Name: ` ; `,. CN/ICR ' -
Version:2013.1
DEFENDANT
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'ti
� Payable Citation/Method of Payment
To find o�:if your citation is payable without a court appearance,how much to pay,or to pay
your fin�,choose one of the following methods:
• Online:Using MasterCard or Visa,access 2ndweb�av.courts.state.mn.us. Have your
- citation number available.
• BV Phone:Using MasterCard or Visa,call 651-266-9202.
• Bv Mail:Check or Money Order payable to Ramsey District Court. Send to:
Ramsey District Court
Traffic Violations Bureau
15 West Kellogg Boulevard-Room 130
St.Paui,MN 55102
Include a copy of your citation number or indicate th�citation number on the check or money order.
You have the right to appear in court. You must pay the amount c�2d or schedule an appearance within 30
days. To make a payment call 651-266-9202. To plead not guilty,or to plead guilty and offer an explanation,
take the following steps:1)after 10 business days,call 651-266-9202;r confirm that the citation has been filed
with the Coart,and 2)request a hearing officer appointment. You musf have a photo ID with ycu when meeting
with a hearing officer. Please allow 10 business days from!he date you receive your citation for processing
before calling.
BY PAYING THIS FINE(S),YOU ARE ENTERING A PLEA Or GUILTY to this offense(s)and voluntarily
waive your rights to the following:(Minn.R.Crim.P. 23.03)
1. To a cour?trial,if the offense is a petty misdemeanor,or a court cr jury trial for all other
offenses;
2. To be represented by counsel;
3 To be presumed innocent until proven guilty beyond a reasonable doubt;
4. To confront and cross examine all witnesses;and
5. To either remain silent or to testify on your own behalf.
A plea of guilty will result in a conviction. If convicted, you must pay a state imposed surcharge under
Minn. Stat.§357.021, subd.6. The current amount of the required state surcharge is$13 for parking-
related offenses and S75 for all other offenses(Minn.Stat.§169.99). Additionally,a law library fee will be
owed. These surcharges and fees are included in the total p?yable amount provided to you by phone or
web.
, Under Minn.Stat.§480.15,subd.10c,unpaid fines may be referred for collections. You have the
right to contest the referraL
Issuance of a worthless check to the court is a crime,and you will be subject to civil and crimina!�?nalties.
In additien,a charge of up to$30 will be assessed on all returned checks(Minn Stat.§604.113,subd.2).
Other important notices regarding your rights can be found on the Minnesota Judicial Branch website at:
www.mncourts.gov/fines
If a Court Appearance is Required
Ce�tain charge(s)require you to appear in court. To verify if the charge(s)you have received require a court
appearance, please call 651-266-9202. If you must appear in court,a Notice to Appear indicating a court
date and time to appear will be mailed to the address on the citation. If this address is not correct,you must
immediately notify the court at the number noted above of your current address. If you have questions
regarding the charge(s),call the number noted above.
Penalties for Failure to Appear or Respond
Failure to appear or respond as required may result in the following:
• The Department of Public Safety and/or the DepaRment of Natural Resources may be notified
of your failure to appear and/or conviction,depending on the charge(s). These agencies may
suspend your driver's license or DNR Iicenses for failing to appear
• A warrent may be issued for your arrest..
• Late penalties may be assessed.
• For Petty Misdemeanors,and Misdemeanors Certified as Petty Misdemeanors,failure to
appear or respond as required is considered a waiver of the right to trial,and a guilty plea and
conviction will be entered on the charge(s),unless the failure to appear is due to circumstances
beyond your control. (Minn.Stat.§169.91;609.491;Minn.R Crim.P.23.04-23.05.)
Report defective meters by noon of the next business day-have meter number available.
St. Paul: 651-266-9776 U of M Campus: 612-626-7275