Hall RECEIVED
MAR 0 6 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, lV��es���RK
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 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 OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name�CJx.-� Middle Initial Y�Last Name �F�LL,
Company or Business Name A!/
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address ���S�II�II�IY\ QcJC, C.
City �- p�L- State � 11� Zip Code���4
Daytime Phone(�)�5,�-��Cell Phone(G3� `�-��Evening Telephone( /V �-
Date of Accident/Injury or Date Discovered I a-1$—13 Time %a� am�i
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. T �.,r+�s Dr�..2rcec�
� 00 �' �uS
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Please check the box(es) that most closely represent the r'eason for completing this form:
O 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
O Other type of injury—please specify
In order to process your claim youu need to include couies of all anplicable 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 is5ued 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
andlor 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—qlease complete this section
Were there witnesses to the incident? Yes No nkno (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes �c 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.
/V Y�e
Please indicate the amount you are seeking in compensat�on or what you would like the City to do to resolve this claim
to your satisfaction. � ���� �—�D '
Vehicle Claims—please complete this section �check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section �J check box if this section does not anplv
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
�tCheck 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 a-I�-l�
Print the Name of the Person who Completed this Form:_�f�_���-�e�-c� 1���
Signature of Person Ma'ng the Claim: - �
Revised February 2011
COUNTY OF FtAMSEI(
DISTRICT COURT
INCIDENT AND CITATION INFORMATION
INCIDENT ID PAYMENT PLAN CITATION NUMBER
2735833 620901366652
DEFENDANT NAME STEVEN MATTHEW HALL
ADDRESS 1095 GERANIUM AVE E
ST PAUL MN 55106
DEFENDANT INFORMATION
DATE OF BIRTH 10/1/1979 GENDER
HEIGHT EYE COLOR
WEIGHT DL NUMBER DL STATE
RACE HISPANIC (Y/N) �
OFFENSE INFORMATION
C�ATElTIM� 12/18/�013 08:25 DfViSION RAMSEY COUNTY
LOCATION FRANK ST AND ROSE AV E COMMUNITY ST PAUL
AGENCY ST. PAUL POLICE DEPARTMENT
METER ISSUING METHOD LEFTAT SCENE
OFFICER 1 742000 CN
OFFICER 2 NBRHOOD
VEHICLE INFORMATION
PLATE 702ENY MAKE CHEVROLET
STATE MN MODEL
PLATE YEAR COLOR WHITE
VEH TYPE PASSENGER VEHICLE VIN 1GCEC14V24Z179782
VEH YEAR
RESPONSIBt,E PARTY . ID METHOD
NONE
CHARGE INFORMATION STATUTE/
STATUS REASON JURISDICTION ORDINANCE DESCRIPTION
CL05E POLER �TPAUL 161.03 Snow emergency parking restrictio►��
ORIGINAL FEE INFORMATION AMOUNT DUE
$40 FINE 40.00 $40 FINE .00
LATE FEE 5.00 LATE FEE .00
LAW LIB PARKING 3.00 LAW LIB PARKING .00
Srchrg-2nd District 1.00 Srchrg-2nd Dist�ict .00
Srchrg-Pa�king 2009 12.00 Srchrg-Parking 2009 .00
GRAND TOTAL 61,00 GRAND TOTAL .00
OFFICERS COMMENTS
SNOW EMERGENCY, CN 13267540, VEH PARKED ON DAY PLOW ROUTE, HAS NOT BEEN PLOWED
CURB TO CURB
£�,:
fre Ioas ecua, �fmdow !�
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�£ 2735833 Sqria: CLOSE I�ain C�srye: OW EMERGENCY PKG �K�00/00/0000�:00 Aye Eva1 OC 19/2014 Pend
DslsedanC STEVEN MATTHEW li�Citatlon: 620901366652 Olns OC 12/18/2013 0825 FL4RGES NOT PENOEO
Incideiri (Charges �Imposed Fees I PaymeM History Evanb I Other System ID's I
? Event HNtory
� Eveat 00te Sourca Carm�snt
ENiERED � 2/19/2013 4:38 AM ACES INTERNAL NCI�NT EhfTERED
AND ADD�t RE�STD � 2l20f2013 12:35 AM DMV MN:SEND E AND ADDRESS RE�UESTEO FROM STATE
OMV DL NUMBER RC � 2/20f2013 7:03 PM DNN Nal:RECENE N DMV Dl NUMBER RECENED G117048509009 NOT U�ATED
ANpADDR RETRND � 2121U2013 7:03 PM DMV MN:RECENE E AND AODRESS RETLIRNED FROM STATE
TE FEE ADDEO � 1/19l201d 12:34 AM FEE�AANAGER TE FEE ADDED
TE NOTICE PRINTED � 1N912014 1'OOAM LATENOTICE TE NOTICE PRINTED
SET - 1l23l2014 9:00 AM Mcla M SET 2/14l�4 2 30 MW
EF�tOR 4i2014 2_30 PM GR/�8�(YW E�AERflENCY PKG(NPLEA)OIS�MSSED-POLICE ERROR
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Total: � `t34.50
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fIMNK YOU!
DatelTime Released: 12/19/2013 19:36 Tow Charge: $ 123.95
Released to:TOTO �� Storage Charge: $ 15.00
\ Admin Char e $ 80.00
Paid by: CREDIT CARD l g �
Released by: LARRY
`,\ �' Tax: (7.625%) $ 15.55
l,the undersigned,have recovered the vehicle described above. Subtotal: $ 234.50
I wili check the vehicle for damage or any other probiems that
� may have occuned while this vehicle was in the custody of the Senrice Charge: $ 0.00
,� Saint Paul Police Department. I acknowledge t will report
y damage andlor any other problems to the Impound Lot staff Total Charges: $ 234•50
� on this form prior to leaving the impound lot.
jDamage and/or other probiem:
Police Report made: Yes_No_,IF Yes, CN , if NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5/2000
Signature
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