Bear RECEIVED
MAR 2 7 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Min�sTo`�aCLERK
Minnesota State Stutute 466.05 stutes that "...every person...who ciaims damages from any municipality...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 tetephone 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 weel�s 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 .� Q��_ Micidle Initial /T Last Name �� a 1� '
Company or Business Name
Are You an Insurance Company? Yes/�If Yes,Claim Number?
Street Address � � y 6e f �h �If h�t ��/E' IC"--3 �
City � �-- ��� � State 1'' l 1 V Zip Code �.S ��U
Daytime Phone( ) - Cell Phone(��)�3��37Evening Telephane( ) -
Date of Accident/Injury or Date Discovered�d� I � � �� _Time f� " 3 I 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.
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
�7'�VIy vehicle was wrongfully towed�nd/or ticketed ❑ I�vas inJm�ed 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 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 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—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 No 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]andmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
u"7 y e�a.�;4 •--� v�� e l=� S* 5 f-- I���-,- c � �✓� S S/�G
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to,your satisfaction. � -i a►'� Urt 1 S' -S�ee �'��n.� w�� lK r��� � 6a � �-
-f vr w�.�-+- .-�- �,�:1- -1 v �� y -F�T --��� -�v c,�;n 9 f C� �
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year OUV Make O Model . oL��
License Plate Number U f-1 !�w� State M�1/� Color ��C e►�
Registered Owner �3"�11� I�E'li�
Driver of Vehicle i�l,.. B e��l
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—nlease complete this section ❑ 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
�heck here if you are attaching more pages to this claim form. Number of additional pages D3.
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 � � J ` �
Print the Name of the Person who Completed this Form: � �►'` � � � � �
l
Signature of Person Making the Claim: �'-
Revised February 2011
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I�I�nnesota 2nd Judicial District ���
Ramsey �oun�y �. ...��,tL�.oUN A +��
15 W Kellogg �ivd Room 130
Saint Paui MN 55102 �� -�:
Phone: (651) 266-9202 - _
Return ?his Portion With Your Payment �����`�.
I Illlf�Ilil!Illll llill IIIlI IIIII illll IlIII fllll IIIII IIIII IIIII lill IIII
JOHN ANTHONY BEAR Citation No(s): 620901396024
874 E GERANIUM AVE, Plate No.: MN 609HDM
ST PAUL, MN 55106 Vehicle Make: FORD
Pay Before: 02/16/.2014
Baiance Uue: $121.00
Date of Notice: 01/19l2014 Amount Enclosed:
- -- — -- - -- -- ___ _ __ __—_ --- —— -
1c
Late Payment Advisory and Final Demand Notice
A citation for Expired registration in Ramsey County at MENDOTA ST AND GERANIUM AV E was issued to you, or a
venicfe r�gistered in your name or 12/18/13 at 8:35AM. This citation has not been responded to within the required 30
days. A$5.00 iafe f�e has �aeen added to ths ba!ance due.
If the citation is not paid before 02/16/2014 and yau uo not appear to contest the violation, a$25.00 delinquent fee will
be added to the baiance due. Under 9Vlinnesota statute 480.i 5 suod 10c, the District Gourt may refer any portion of the
fine, surcharge, court costs, or fee that you fail to pay by the due d�te to a collection agency. The Court cannot accept
payment for a citation or.ce it has been r�fe�red to a coAecfion agen4y.
Additional collections efforts that may occur are:
+ Refer your account to a privat�collection agency
s Offset of your state tax refund
� Tow your vehicle
♦ Recommend your drivers license be suspended
� Recommend yo�r hunting ar fishing privileges be suspended
� Access non-public government data on you for the purpose of collecting this debt
� To co�itest a citation or collections ref�rral, you must make an appaintment to see a hearing officer by calling
651-266-9202 before: 02/16/2014
♦ You must bring this notice and a photo ID with you when you appear for your appointment.
o Make checks payab;�?� Ramsey Distriet Court. Wriie the citation number on your check and mail it with the
top sectior: of this notice in the enclosed enveloFe.
♦ Do not send cash.
� �!ease allow 5 business days for processing.
v Pay on the internet with a check or cre�it card. eivww.2n�wreb�ay.courts.state.mn.us
�► Ta pay by phone with a rnajor credit card caii 651-266-92G2. F-iav�this notice wi#h you when you call.
If you believe this notice has been sent ta you in error please call 651-266-9202.
7his is Your Final and Only Notice
For your records: Citatior.#: 62Q901396024 Offense Date: 12/18/13,Amount Due:
$121.00