Christian, Janet (2) �EC�IVED
MAR 10 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne�siTa d��eE RK
;
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shaU cause to be presen e I
governing body of the municipaliry within 18d days after the alleged loss or injury is discovered a notice staring the time,place,and �
circumstances thereof,artd 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 eicplain 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, 5AINT PAUL,MN 55102
� < <
First Name �' Middle Initial�Last Name C h n � s �' ��
Company or Eusiness 1lame
Are You an Insurance Company? Yes/No Yes,Cl ' Number?
Street Address � � � � � /
City State
_ �/�� Zip Code (�
Daytime Phone � ����Cell.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 ancl/ r responsibl for our damages. , �
G�`�
JL .
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 wac 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 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 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 comulete 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,intersectio�,qame o_f,�ark�f�ci �ty, h1��„J�
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. �'r���� --��J ��
; �_��
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. �r�1 / Q... �,'" �
Vehicle C7a�ims=-�Iease com lete this section ❑che box if this section does not a 1
Your Vehicle: Year Make �d j'��Model ��'Z -
License Plate Number�j� CU i�V U� 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 � ❑check box if this section does not apnlv
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))
Naine 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 informrztion 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 Form: ����,g.���i^ a - � Q�
� �'
Signature of Person Making the Claim: � �-'` !L
Revised February 2011 �
� 1
' �_ _ CITATION � �- '
!' State of Minnesota � ,
' Citation#: I IIIIII IIIII IIIII IIIII IIIII IIIII IIII)IIIII IIIII IIIII IIIII IIIII IIII I�II
; 620900223243 620900223203
' County Name: Sequential Citations_of_
'i r.f
Identification: ❑DL ~❑4�/S,'Web ❑Photo ID ❑FP ❑Other
! DLNumber ��- �
MN ❑CDL ❑State
� Name: First Middle Last Suffix
. Address—Street,Apt# �
City State Zip �
� 1!
i DOB(mm/dd/yy) Height Weight Eyes Gender O I
I
� 0 �
❑Juvenile Court Parent or Guardian's Name: ❑Same Child's
� Offense. Circle One: address as Race Q �
� JTR,JPO,DEL Address: Juvenile � E
; Veh.Lic.No. Plate Year State Make Style ❑16+pass. Color N `
, � w
� Date of Of�ense � Time of Offense ❑AccidenUCrash � N
❑Pro e ❑In'u ❑Fatal ❑Pedestrian O
+ ❑Unsafe conditions ❑Endangering Life or Property* ❑Commercial Vehicle � j
Weather: *Court appearance required if checked DOT# 1
� #Pounds overweight �
❑Hazardous Material D07
❑Driver ❑Owner ❑Passenger ❑Operate ❑Parked ❑Booked
j Offense�ocation. �ircle One: CitylCpuntylTownship/Othee
j Offense Change Description StatutelOrdinancg ❑3rd` PM,M
_ '�"'/(�� t+�� violation GM �
_ . ." s . .'` •;
� Offense Change Description ` StatutelOrdinance ❑3rd PM,M �
�
- , violation GM
' Offense Change Description StatutelOrdinance ❑3rd PM,M
j 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 }
E
�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 No s � Prosecutor
Officer(s)Name(s) •. � ;, •V� ( ) , ��
.
�i Controlling Age (CAG) How Issued a,� Date Issued
` MI�}�900 ❑ In Person ❑ Mailed C�I Left at Scene
� Agency Name: ° _' CN/ICR ' - �
Version:2013.1
� DEFENDANT
{
`�� Payable CitationlMethod 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 MastarCard or Visa,access 2ndwebpay.courts.state.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 Court. Send to:
Ramsey District Court
Traffic Violations Bureau
15 West Kellogg Boulevard-Room 130
St.Paul,MN 55102
include a copy of your citatio�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 3Q
days. To m�ke a payment call 651-266-9202. To plead not guilty,or to plead guilty and offer an explanation,
take the folEowirg steps:1)ak2r 10 business days,eall 651-26F-9202 to confirm that the citation has been filed
with the Court,and 2)request a heariny officer ap�cintment. Yuu must have a photo ID with you when m2eting
with a hearing officer. Please ailow 10 business 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 u court trial,if the offense is a pet!y 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 testif�j vn your own behalf.
A plea of guiity will result in a conviction. If convicted, you must pay a state impcsed 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 off.enses(Minn.Stat.§165.9°). Additionally,a law library fee will be
owed. These surchary�s and`ees are included in the total payable amount provided to you by phone or
web.
I Un�er 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 criminal penalties.
In addition,a charge of up to$30 wili be assessed on all retumed checks(Minn S:at.§604.113,subd.2).
Other imp�rtant natices regarding your rig�ts can tre found on the Pvlinnesota J:adicial Branch website at:
www.mncourts.pov/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 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�►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 Naturaf 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 license�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. Subtotai: $ 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
5/2000
Signature
_�_� . -