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Lee, Eddie RECEIVED NOTICE OF CLAIM FORM to the City of Saint Paul, M nAnes�t��� Minnesnta Stute Stunitc:466.0_5 state.r thut "...ever��perso�:...whn claims�tunue�es from am�municipality....rhull ca��to Se�f���l Mlke gnven�ing bodY of the ntttnieipality within 1 RO davs after the alleged Inss or injun'is discnvered a notice statrng the tinae,place,and circumstances therenf,und the amoa�nt of compensation or other relief ctemunded.° 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 wfll 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 wiil receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature af 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 �QO 1 E Middle Initial �LasE Name l_E� Company or Business Name il��� Are Yau an Insurance Company? Yes No If Yes, Claim Number? N�� Street Address CJ�rJ l'�_o/�v - x�t; �T City ��1T �AvL State �`'`/V Zip Code 5�t0� Daytime Phone(�)��Z Cell Phone( ) - Evening Telephone ( ) - Date of Accident/Injury or Date Discovered D�•��•Zt'�l y Time D t 30 �/pm Please state,in detail, what occuned(happened),and why you are submitting a claim. Please indicate why or how you feel the City af Saint Paui or its employees are involved and/or responsible for yow damages.�._�2•2!•.2n,� ����t���-kT��� l��gt�b��, � �eT�ce�c� 'TKA�r' �►�J w���`s vgNCC�.C- — �,�� �Ca S/�T� �Q�,1.A.__T�'�. • �C H� - /�f� � �Et/ 'Tot.�� ��Cj To b sN e Mt3 Q� ewt �,�PeN iAL��F)�fATldl1�.� T �F�S�f� ?I�.hT ?'HE .l71ZS�r?' ,w..• ��`S Q���� O-�—W AS N�'jT_�aST 8''D AS A Iu1 t�H'C Pl�fw� -y fl �l-� Ta A�—.��9'-�j�l �. 1�+►P�°`�"''�p (^�� Please check the box(es)that most ciosely 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 �iy vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage-please specify ❑ Other rype of injury-please specify In order to process your claim vou need to include copies of all apalicable documents. For the claims types listed below,please be sure to include the documents inciicated 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 g2 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 bi11s 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—qlease complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephone numbers: N1�4' 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,name of park or facitity, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.S F S�D E oF �,nM��,�] �C H�o.� H�t,flO..���5 t�os aTi4L Please indicate the amognt yo�4 ki�in compensation or what you would like the City to do to resolve this claim to your satisfaction. �� � i Vehicle Claims—please complete this section ❑check box if this section does not avplv Your Vehicle: Year Make Model License Plate Number 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 Qlease comnlete 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(circ(e) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Te(ephone 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 f�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 information you have provided is true and correct to the best of your knowledge. Unsigned fornzs witl not be processed. Submitting a false claim can result in prosecution. Date form was completed �y' � B '�7 Print the Name of the Person who Completed t s Form: �Ts'1� � � �--E C Signature of Person Making the C7aim: Revised February 201 l � cn O ° � ' °' °' � g• � rn � c�' � � � �► 3 ��c � m c� �- � � m � � � � � � � .* � o c N Q �, � e-t � � � � o � cm � � °� (� ° m G' � , n � Q' � o � � �c° ` p —I m � � _.\ � � o o � �' � s � Z � � y D O , c a � o ,� o S' � � ? D � ,`g,. ci � -, � °�° � � < 'T� � a (D -� -a a, � n� . �, m rn � u � � � �. � � m o � � n�i � �' � � \ _ ' (D � 0 j 3j' N C N fn Z � � � _ N � fp O C � � � 3 � v ?� Q o r' � " co L3. O �t � ° � � � ii' � r � � < <" c�'u O � � �- � � cn � � � �7 �, ° °' � ° c� .i 00 Z n vm3f?pQ W W � Z � �. � �° � � m Oo � � I � � � � Q � _ � � �� � � Q ,''�..' � rn � � o N � n � � � � � g z � _ �' -- � ; s� � g � D Z o c�p c o�i Da � o w N � O � z � x 3 � � o m s �u v � n m � � O � � � � � 5 � s � � � � a � � m '"'' � � fD � � rm � Cta rs� � bn cs► � tfl n N N � � � _a 7 (D N < -i � � � U�i O � � N � m � r oNO cND O `� O � � � N 8 0 //1 b � � -� r CITATION , ,��� ; S�te of Man,esota � � �� r, ,..�'" � � j � CitaHon#� ���� ; :. I�� 620900215217 s2osoo21�2�7 � state -___ ; � pt Number ❑MN ❑CDL , r � Name = Fjret Mld�le last Addtess-Street�APt# Gity State �P �� ' DOB(mm/ddhryyy} Eyes Height WeigM Sex Race �thniary � � � { < � � Vehicl6 Lic�tse No. Plate Y r Stat _Make T a°� :�'t j y/ � �,. � �� T � R Data of T � p p,a�eny ❑�n ❑Fare� ❑ped�n � ` � * parki» Meter Number Neighborhood C o d e ❑Housu►91Builiding Code N � . n9 t �� ❑P�ger O Driver ' � � ❑Booked te ❑Owner D � t p({ense Locadon '��„ 1 f i C � � ... � ; i .�... ..r✓� , �°�� � No 1 0(fense � � � �: .„� � �;,,°• � � � E, . No 2 Offense .�. �- t � d z �� ����No 3 Offense ��� ��� p Speed 169.1d(s,�F„� ):' mph zone . CI No Seat Belt Use 169.686.1(a) ❑No ProoS of Ir�urar�ce 169.791{2) A�Taken-A�: . Test type: ❑ Refused ❑ Breath ``❑ Btood' ❑ Urine k` O Hazardous Material(D0� ❑Unsafe Condidans O Schoo�Zone , — � ❑Endan eri L'rfe&Propeeh' ❑Wak Zone 0 Comrt�err�al Veh. DOT� � Ide�tion: ❑DL ' ❑DVS Web ` 0 Photo ID ❑Other See pack of citation for information on paying your fine. � See li cited tor No Prooi of Insura�or fdo Ddves's Lisense in Possession,Proo1 of Insurance ar�d/or + Oriver's License must be shown at o f��d g��Ct�ation s'filed��v+ith'the Court.��of this � � citation within 21 days � Please read the;back of this cifation caretul and respend. � t �" # � � � � # ot1�(s?►�r►�e(s1 OFficer Wois),..`° °��., CiJ�� �� �, �p�. � How is�ted �tn F'etsan ` 0� � �,;�` ` � DEfENDANT _ . �, ,: � .� _ . . -.�__ __.. ��b R�crs� o�AcTroNs Cnse No.62-VB-14-681 State of Minnesota vs 6ddie Cheu-I�ku Lee § Case Type: Crim/Traf Non-Mand § Date F�ed: 03/24/2014 § Ramsey § Location: Crim inaUTraffictPetty § Dow ntow n PAliTY LVpORMATION Lead Attorneys Defendant Lee,6ddie Cheu-Ntu Male ST PAIR,11M 55106 DOB: 10/30/1980 Jurisdiction State of Minnesota CanRC�Ivc«cMAnov Charges:Lee,Eddie Cheu-Ntu Statute Levei Date 1. Snow emergency paridng resVictions 161.03 F�tty Nisdemeanor 02/20/2014 E�'ENTS RL ORDERS OF Tig COI:RT DLSPOSI7iONS 03/24/2014 Plea(Judicial Officer:Grabosky,WiNiam) 1.Snow emergency parldng restrictions Not guilty 04/28/2014 Disposition(Judicial Officer:Bartsh,Shawn M,) 1.Snow emergency parlang restrictions Dis►rissed O'II-IFR EVIN'I5 AND HFARINGS 03/24/2014 Citation EFled 03/24l2014 Officer Notes 03/24/2014 Notice and Order to Appear 03/24/2014 Summoned-Own F�cognizance 03/24l2014 Interim Condition for Lee,Eddie Cheu-Ntu -Summoned 03/24l2014 Hearing (9:00 AIV�(Judicial Officer Grabosky,Wli liam) Resuft:Held 04/28/2014 Hearing (9:00 AW�(Judicial Officer Bartsh,Shaw n M,) Result:Held 31tb <'�r . i . � :. � €. � r C (� Cr-- � � � � � � d z � � o � � N d � � N � � r _ �s � � � � � r� ° o ��{ � r \� n a i.!1 V' v �` � � � � � t' � � ` 3 � � �.� Q � � � � � � �� � � o � � � z N � � � • o � � � � (� _ o � � � d � � �- ��, ��� � � ��'�=�� f , �� r .��{5.�t. � ;�,4 dR �� � - . i� � +F - a 2�` �' � ' N '�.F� h. � .t �� a � � £ �� �.� � < . � y, [' �� ;° �. ������� �� .. ,'�— � � t 1; :� � �� � ..,s,� �,�.., .. r,�*��i c�=. . `-� �:. :, � ,Lw�' ` ' . 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