Christian, Janet RECEiVED
MAR 10 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne�siTa ERK
Minnesota State Statute 466.05 states that"...every per.son...wno claims damages from any municipality...shall cause to be presenied��ie
governing body of the municipa[ity within I Sd 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 acl�owledgement 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
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First Name Middle Initial.�Last Name ��`I n v' L� z Q y�
Company or Fusiness Name
Are You an Insurance Company? Yes/No Yes,Cl ' Number?
Street Address � � � � /
City
State - � Zip Code . � `�
Daytime Phone ! ����Ce11.Phone(_) - Evening Telephone(_) -
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 ind' a e why r how you
feel the City of Saint Paul or its employees are involved andl r responsibl for our damages. �
G�'�'`�
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f � .
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
❑ y vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
�y vehicle was wrongfulJ.y towed and/or ti�keted ❑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 you need to include copies of all auplicable 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 andlor 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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease 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? Yes 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, me of ark or f i 'ty,
closest landmazk,etc. Please be as detailed as possible. If necessary,attach a diagram. ���C��° q�h'�1��
�
Please indicate the amount you are seekin in compensation or what you would like the City to do to re'solve this claim
to your satisfaction. ��` qa �?'" �
Vehicle Claims— lease com lete this section ❑chec box if this section does not a 1
Your Vehicle: Year Make �d j�.� Model �� -
License Plate Number�'� (U UU� State�.�_Color
Registered Owner ✓� �Q�:� ✓
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iqjurv Claims—please comnlete this section � ❑check box if this section does not annlv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes o Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address elephone
Did you miss work as a result of your injury? Yes N
When did you miss work? (provide date(s))
Name of your Employer: __ '
Address Telephone
❑Check here if you are attaching more pages to tlus 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 �
i
Print the Name of the Person who Completed this Form: ��-y�g� �6 . i 2�
�
Signature of Person Making the Claim: �.-f �L
Revised February 2011 .
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� L__ CITATION I �-
' State of Minnesota IIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�I
' Citation#:
� 620900223203 620900223203
County Name: Sequentiai Citations_of_
's:
Identification: ❑DL ❑qVS?Web ❑Photo ID ❑FP ❑Other
: DL Number " MN ❑CDL ❑State
Name: First Middle Last Suffix �
. �
Address—Street,Apt# �
r
City State Zip ;
Q� j
� DOB(mm/dd/yy) Height Weight Eyes Gender O 1
1
: ❑Juvenile Court Parent or Guardian's Name: ❑Same Child'S 0 �
Offense. Circle One: address as RaCe Q
JTR,JPO,DEL Address: Juvenile � �
, Veh.�ic.No. Plate Year State Make Style ❑16+pass. Color N '
, , . . .
, r �
, , ,
: . ._:. . �-
j Date of Ofjense Time of Offense ❑AccidenUCrash , �
! ,_ '"`' ❑Pro e ❑In'u ❑Fatal ❑Pedestrian O
� ❑Unsafe conditions ❑Endangering Life or Property* ❑Commercial Vehicle � i
Weather. "Court appearance required if checked DOT# y
j #Pounds overweight:
❑Hazardous Material DOT �
❑Driver ❑Owner ❑Passenger ❑Operate ❑Parked ❑Booked
� Offense�ocation, �ircle One:City/CpuntylTownshiplOther
Offense ChangeDescnption Statute/Ordinancg ❑3rd PM,M
""��((G� c*�3 violation GM �
Offense Change Descnption , j Statute/Ordinance ❑ 3rd PM,M f
' violation GM
Offense Change Description StatutelOrdinance ❑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 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.
See the back of this citation for more information. '
, Officer(s)Name(s) t � � , Officer No(s) , _:? Prosecutor
,�, . .�...;� i
Controll�in�g�A�ge (CAG). How Issued -^.� Date Issued ;
� MNC1�Vy00 ❑ In Person ❑ Mailed �J L at Scene �
� Agency Name: ' .? CN/ICR `
. I
Version:2013.1
� DEFENDANT
i
'� Payable Citation/Method of Payment
To find out if your citation is payable without a court appearance,how much to pay,or to pay
your fine,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.
• By Maii:Check or Money Order payable to Ramsey District Court. Send to:
Ramsey District Court
Traffic Violations Bureau
15 West Kellogg Boulevard-Room 130
St.Paul,MN 55102
Include a copy of your citation number or indicate the citation number on the check or money order.
You have the right to appear in court. Yau must pay the amount owed or schedule an appearance within 30
days. To m�ke a payment call 651-266-9202. To plead not guilty,or to plead guilty and offer an expla��ation,
take the folEowing steps:1)a'±er 70 business days,cali 651-2E�-92i12 to confirm that the citation has b2en filed
with ttaa Court,and 2j request a hearing officer appointment Yuu must have a photo ID with you when meeting
with a hearing officer. Please a1low 10 busiress days from the date you receive your citation for processing
before calling.
BY PAYING THIS FINE(S),YOU ARE ENTERING A PLEA OF GUILTY to this offense(s)and voluntarily
waive your rights to the following:(Minn.R.Crim.P. 23.03)
1. To a court trial,if the offense is a pet?y misdemeanor,or a court or}ury trial for all other
offenses;
2. To be represented by counsel;
3 To be presumed innocent untii proven guilty beyond a reasonabte doubt;
4. To confront and cross examine all witnesses;and
5. To either remain silent or to testifij on your own behalf.
A plea of guilty will resul;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$76 for all other offenses(Minn.Stat.§169.9°). Additionally,a law library fee will be
owed. These surchary�s and fees are included in the total payable amount provided to you by phone or
web.
� Under Minn.Stat.§480.15,subd.70c,unpaid fines may be referred for collections. You have the
right to contest the referral.
Issuance of a wo!thless check to the court is a crime,and you will be subject to civil and criminal peralties.
In addition,a charge of up to$30 will be assessed on all returned checks(Minn Stai.§604.113,subd.2;.
Other important nctices regarding your rig�ifs oan i�fcwnd or,the�d!innesota Judicial Branch website at:
www.mncourts.QOV/fines
If a Court Appearance is Required
Certain 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 ycu must appear in court,a Notice to Appear indicating a court
date and time to appear will be mailed to ihe 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.
I Penalties for Failure to A
ppear or Respond
Failure to appear or respond as required may result in the following:
'L. � The Department of Public Safety and/or the Department 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 licensec 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
�
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 13 FORD License#: CNW2405 CN: 14033708 Invoice#: 29124
Date/Time Released: 02/21/2014 06:35 Tow Charge: $ 123.95
Released to: TSBE Storage Charge: $ 0.00
Paid by: CASH Admin Charge: $ 80.00
Released by:ADAM Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
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 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 si2000
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