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Smith, George RECEIVED MAR 10 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota �ITY 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 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 � �� f First Name `��C�JQ-4 Middle Initial Last Name 6' `� Company n;Business Nazne Are You an Insurance Company? Yes/No If Yes,Claim Number? Street Address%/�� -.L�L� �1�' /��-�� - City�/��C State�� Zip Code��1� Daytime Phone(_) - Ce11 Phone((�/�)��Evening Telephone(_) - Date of Accidend Injury or Date Discovered Time 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 o�,e�loy s e involve d/or responsible for your damag s. � ':/ � vam r � < / �� r � 0 '� 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 �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�nclude copies of all apnlicable documents. For the claims types listed below,please be sure to include 7he 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 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-ulease 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 N 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�k or f it , �i`aL�'U' closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. /l�� c� 1��" S��Od.� !�'I fJ Please indicate the amount you are see,�cing in compensation or what you would like the City to do to re'solve this claim to your satisfaction. .�� `1`� Vehicle Claims- lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year f��Make �' ��<'�- Model '1 License Plate Number��j `I' State��.Color , T Registered Owner��r��s� .�,��1 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-nlease comnlete this section ❑ check box if this section does not apvlv 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 tlus claim form. Number of additional pages By signing this forin,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. Submittin a alse claim can result in prosecution. Date form was complete�'�/g/� � g f Print the Name of the Person who Completed ttus Form: �='��e�?k��1r�,�"j�` Signature of Person Making the Claim: �- - - ��`�� Revised February 2011 i l �I � � CITATION � � iState of Minnesota � Citation#: ��IIIII II�I��IIIII IIII IIII � 620900�23161 62QJ00223161 � County Name: Sequential Citations_of_ i Identification: ❑DL ❑DVS Web ❑Photo ID ❑FP ❑Other � DL Number MN ❑CDL ❑State — I � ( Name: First Middle Last Suffix � I � I �I Address—Street,Apt# I City State Zip � � I DOB(mm/dd/yy) Height Weight Eyes Gender � ❑Juvenile Court Parent or Guardian's Name: ❑Same Child's Q Offense. Circle One: address as RaCe Q JTR,JPO,DEL Address: Juvenile � Veh.Lic.No. Plate Year State Make Style ❑16+pass. Color � , � � Date of Offense Time of Offense ❑AccidenUCrash � � ❑Pro ❑InL ❑Fatal ❑Pedestrian � � ❑Unsafe conditions ❑Endangering Life or Property ❑Commer�ial Vehicle � Weather: 'Court appearance required if checked DOT# #Pounds overweight: ❑Hazardous Material DOT ❑Driver ❑Owner ❑Passenger ❑Operate ❑Parked ❑Booked Offense Location Circle One: CitylCounry/Township/Other � Of: Offense Change Description Statute/Ordinance ❑3rd PM,M 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 Statute/Ordinance ❑ 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) Offcer No(s) Prosecutor Controlling Agency(CAG) How Issued Date Issued MN0620900 ❑ In Person ❑ Mailed ❑ �eft at Sc$ne Agency Name: CN/ICR Version:2013.1 - - DEFENDANT Payable CitationlMethod of Payment To find out if yc�ur 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.courtsstate.mn.us. Have your citation number available. • By Phone:Using MasterCard or Visa,call 651-266-9202. • By Mail:Check or Money Order payable to Ramsey District CouR. 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. You must pay the amount owed 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 explanat�on, take the followiny steps:1)after 10 business days,call 651-266-9202 to confirm that the citation has been filed with the Court,and 2)request a hearing officer appointment. You must have a photo ID with you when meeting with a hearin�,i:`icer. Please allow 10 business days from the date you receive your citatfon for processing before calling. BY PAYING THIS FIN�(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 petty misdemeanor,or a court or 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 wiil 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�a76 for ail other offenses(Minn.Stat.§169.99). Additionally,a law library fee will be owed. These surcharges and fees are included in the total payable amount provided to you by phone or web. Under Minn.Stat.§480.15,subd.10c,unpaid fines may be referred for coliections. You have tha right to contest the referral. Issuance of a worthless check to the court is a crime,and you will be subject to civil and criminal penalties. In addition,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 6ranch website at: www.m ncourts.gov/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 couR 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 cn 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 apNear or respond as required may result in the following: • The Department of Public Safety and!or the Departrent 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 licenses 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 Impounc Lot, 830 Barge Channel Road, Vehicle Release Form _ Make: 99 CHEVROLET License#: UVT819 CN: 14033708 Invoice#: 29178 , Date/Time Released: 02/21/2014 06:24 Tow Charge: $ 123.95 Released to:TOTO 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 tmpound 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 . � � N � � , � 6 c � �