MacLeod-Roth � � RECEI�IED
APR 0 4 2014
NOTIC� OF CLAIM FORM to the City of Saint Paul, ]��e�ctt�RK
Mr�inesotn Stcrte Stutute 466.05 stntes that " ...every person...whn clnints dcrmages.`ro���mty numicipn/iry....chn/l crru.ce�o he presc�rtcd tn!he
guverning bud y of d�e rnunicipality withrft /80 dm�s nfter t/te alle�ecf loss or injurv is discuvered n notic•e stnting tAe lime,place,cu�cl
circumstances tFrereof,and the amount nf compensntirni or other relief demnnded."
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�cknowledgement 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 DOCUM�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name�o�� Middle Initial " Last Name �"la.� - �
Company or Business Name N��
Are You an Insurance Company? Yes N If Yes, Claim Number? /J��
Street Address 17�.� ��'D�
City St= 1�'a,v� State �"�/� Zip Code 55 jDy
Daytime Phone (�L) 3l(� -(o�Cell Phone (�)�7(�! - �YO Evening Telephone(J�) ��I- �`��S
Date of Accident/Injury or Date Discovered�S,/I`f Time a 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 emp lo ees are involved and/or responsible for your damages.
/ �.,�< �o�•r� �i�O� fi�rscl�/ s`� l�.ec��.�. D�.�ls�. A.� a.aL Mwst�Rl(� / had ��o,.s�,l{�d � w�,-w ����s
�. � !�, v ka �' f wn de ' as a �� .,.�i K L�U.STOS�c �,
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�a caer��� n•.. vi'�n�'on
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 durinb a tow
`�M❑ y vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
y 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 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
�(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
I�'ailure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please comnlete this section
Were there witnesses to the incident`? Yes �� Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes o 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, tc. Please be as detailed as possible. If necessary, attach a diagram.
�Jsc-�r�2� c� �e{�..�ct� �-,�� �eanuc_ � �1a5h411
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. ��!°l 5v �e. CoS� d� �c.rv�q �S
_ -- . - —
Vehicle Claims—please complete this section check box if this section does not applv
Your Vehicle: Year Zfl02 Make /�(QZa�o� Mode1��4
License Plate Number 7�o�f 8L�6 State�Color �B/a��
Registered Owner � �a•� •
Driver of Vehicle �darv� ��__Le_o�— d�'�
Area Damaged N/f�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims—please comptete this section check box if this section does not apply
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 this claim form. Number of additional pabes ✓ .
By signing tlzis form,yoic are stating tliat ull information yorc lzave provided is trrce 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 � �Z 1 ��-}
Print the Name of the Person who Completed thi Form: /-�d�aY� N��—Ko�
Signature of'Person Making the Claim:
Revised Februxry 201 I
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' � �ITATION �
; .
i State of Minnesota '
� Citation#: I IIIIII II�I)�IIII IIIII IIIII IIIII IIIII IIII IIIII I(II IIIII I IIII IIII
� 620900231435 620900231435
�
;
i County Name: ' Sequential Citations_of_
-� � „
i Identification: ` ❑DL ' ❑DVS Web ❑Photo ID ❑FP ❑Other � f
DL Number
I MN ❑CDL S e �
h n
I Name: First Middle Last Suffix
I ':
I �
i Address-Street,Apt#
;
� City State Zip
i �
, DOB(mm/ddlyy) Height Weight Eyes Gender O
I �
, ❑Juvenile Court Parent or Guardian's Name: ❑Same Child's Q
Offense. Circ;e One: address as Race Q _
JTR,JPO,DEL Address: Juvenile �
Veh.Lic.No.; .- Plate Year State Make $tyle ❑16+pass. Color �
� � -.; z-;, - _ i_" �-,��. -� - . �
� Date of Offense Time of Offense ❑AcadenUCrash �
-- - ` - ❑Pro e ❑In'u ❑Fatal ❑Pedestnan �
� ❑Unsafe conditions Commercial Vehicle �
❑Endangering Life or Property' ❑
Weather. *Court appearance required if checked DOT#
, #Pounds overweight:
❑Hazardous Material DOT
❑Driver ❑Owner ❑Passenger ❑Operate . ❑Parked ❑Booked
� Offense�ocation Cirde One:�itylCounty/TownshiplOther
� - Of: =� -
' Offense � Change Description Statutel0�tlin�rice ❑3rd PM,M
� -, violation GM
Offense � Change Description StatutelOrdinance ❑ 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
I
I
❑Speed Min .Stat.§169.14(subd. ) mph Zone PM,M ❑3rd in 12 months
i �No proof of Insurance Minn.Stat.§169.791 (subd. ) M,GM
I ❑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.
4 Officer(s)Name(s) Officer No(s7 i" Prosecutor
i
Controlling Agency(CAG) How Issued Date Issued
M N0620900 ^ ❑ In Person ❑ Mailed -Q�Left at Scene
I� Agency Name: CNIICR `
` Version:2013.1
�I ' DEFENDANT
IL