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Nelson, Shelia , R�CEI�/ED ' � . :� MAY 0'7 2014 NOTICE OF CLAIM I'a►RM to the City ��i��Minnesota Mrnnesota St�ue Stnttrte 466.05 stotes tha! "...every perso�t...wlio ckii��s dnntnges,%rom any rnufaicipaliry...shnll ctrt�se to he��'esenled to!he goi�ernirrg bucfy q/'t/�e inunicipnlity wid�irt /80 duys nfler the al/eged loss or irtjury is discovered a no[ice stutin,q[he lime.p/nce,and circwns7cri�ces t/rerenf,rrnd the nrnount of compensntron or other relicf demancled." Please complete this form in its entirety by clearly typing or�rinting your answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to clari!'y answers,so provide as much information as necessary to explain your claim,and the amount of compensalion bein�requested. You will receive a written acknowled�;ement once your form is received. The process can take up to ten weeks or longer dependinb 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 -�!/l�/�� Middle Initial�Last Name /V�ON _�- Company or Business Name Are You an Insurance Company? Yes N� If Yes, Claim Number? Street Address / � (P `�' �(��t IU� �� `� � � City � �' �A l�L+ State MN Zip Code S.J � �� Daytime Phone ( ) - Cell Phone (l ��)�� d2, 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 indicate why or how you feel the City of Saint Paul or its em loyees are involved and/or responsible for your dam•ges. C fk✓' w+��5 -t'v�i�=1� . � S� s c��'-'-�- U f' m✓�c��Y.J � . t�O r,-.� uJi�-�- Z '�A/' € Wt C�1 t�'1 �t C�.�'E►�. � r L�a �v o�� -i�c3 l o r�„�-� �.. o�/�4-L u� r+�� -�' •-�e C o J �f'E E -4- E- i�t S O ►� �rs r�' 4n�c �� ' � Lf c�e o n '17-� � E 1 lJ t� L�Y�-fj � rv'l i �C� C�w--✓J +�� •S �'�15 '-'��S t�lW� C=.O -� C'� ��: t 4-`� � "�h , s c�+-i`=�4 n�S � S o v �1 t�f- C.�►A r'�� a r' ��— +c�1� Please check t11e 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 L�1C�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 ro 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 retumed. Page 1 of 2-Please complete and return both pages of Claim Form Failure to complete and return both pages will res�ilt in delay in the handling of your claim. All Claims—nlease comnlete this section �.7 Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enf'orcement called? Yes � No Unknown (circle) If yes, what department or agency? Case#or report# �.72 �.J� �' Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest landmark etc. Please be as detailed as possible. If necessary, attach a diagram. k� '��=-, S�' .5 a��. � L t� c�t�. /k J� .�'�. �4 v l_.-. Please indicate the amount ou are seel:ing in compensation or what you would like the City to do t resolve this claim to your satisfaction. ' ( � C�b �v�� -��L- �- ' S --D o �a b �- ,.� a . �c �- ;� �.�/ I a �k,/�� .� �� ,-,��y Vehicle Claims—please complete this section B check box if this section does not apply 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 Injury Claims—please complete this section G�c e�ck 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 [H'Check here if yuu are attaching more pages to this claim form. Number of additional pages�. By signing tltis form,yocc are stating tltat ull information yoic laave provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecietion. Date form was completed Print the Name of the Person who Completed this Form: ��I�1 �w � `V�Sa�'`� Signature of Person Making the CI�____�l� n' ' /�J � Revised Febru�vy 201 I III�I�IIIG�IIIIIl��I3IIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII �NCIDENT INFORMATION REPORT 5/72014f2 � ' STATE OF MINNESOTA COUNTY OF RAMSEY DISTRICT COURT INCIDENT AND CITATION INFORMATION INCIDENT ID PAYMENT PLAN CITATION NUMBER 2725564 620900880792 DEFENDANT NAME SHELIA DENISE NELSON ADDRESS 1764 GRAND AVE APT 4 ST PAUL MN 55105 DEFENDANT INFORMATION DATE OF BIRTH 1/5/1955 GENDER FEMALE HEIGHT 5 Feet 8 Inches EYE COLOR GREEN WEIGHT 166 Lbs. DL NUMBER K511127241407 DL STATE MN RACE WHITE HISPANIC (Y/N) OFFENSE INFORMATION DATE/TIME 12/03/2013 09:53 DIVISION RAMSEY COUNTY LOCATION WHEELER ST S AND LINCOLN COMMUNITY ST PAUL AV AGENCY ST. PAUL POLICE DEPARTMENT METER ISSUING METHOD LEFTAT SCENE OFFICER 1 412957 CN OFFICER 2 NBRHOOD VEHICLE INFORMATION PLATE 024JWY MpKE VOLKSWAGEN STATE MN M�DEL JETTA PLATE YEAR COLOR SILVER VEH TYPE PASSENGER VEHICLE VIN 3VWRX7AJ1AM037766 VEH YEAR RESPONSIBLE PARTY ID METHOD NONE CHARGE INFORMATION STATUTEI STATUS REASON JURISDICTION ORDINANCE DESCRIPTION CLOSE NPC STPAUL 160.06 Park at meter w/o payment of the meter fee or beyvnd the time permitted by such meter CLOSE CMPLY STATE OF 169.79.8.a Display of plate registration stickers - month/year MINNESOTA stickers required ORIGINAL FEE INFORMATION AMOUNT DUE $20 FINE 20.00 $20 FINE .00 $30 FINE 30.00 $30 FINE 00 LATE FEE 5.00 LATE FEE .00 LAW LIB CRIM/TRAF 10.00 LAW LIB CRIM/TRAF .00 Srchrg-2nd District 1.00 Srchrg-2nd District .00 Srchrg-Crm/Traf 2008 75.00 Srchrg-Crm/Traf 2008 .00 GRAND TOTAL 141.00 GRAND TOTAL .00 �i��l=��IIIII��I�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII INCIDENT INFORMATION REPORT 5/92o14f2 OFFICER�� ORIMENTS -------�� W AWAY ZONE 6AM TO 3PM DEC 3RD ALSO VEHICLE IS MISSING FRONT 2014 TAB YEAR 1 � � ' Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: 10 VOLKSWAGEN License#: 024JWY CN: 13257697 Invoice#: 147948 Date/Time Released: 12/03/2013 11:35 Tow Charge: $ 54.50 Released to: TOTO Storage Charge: $ 0.00 Paid by: CREDIT CARD Admin Charge: $ 80.00 Released by: YOUA Tax: (7.625%) $ 10.26 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 144.76 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: $ O.OG Saint Paul Police Department. I acknow(edge 1 will report damage and/or any other problems to the Impound Lot staff Total Charges: $ 144.76 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 RlGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT Signature 5i2000 r� '�� tU ��'�` ��°� �`� �� ,� � 4 _ _� �� T .. CL"�� __ � 'C'," U o�`"' �` �� ^ � � r,.. �aou . o��,+1 �S'Z � �� CT A� Q1D�yS n i.i� �A Y�y+� � r �r � N m7 � g r+ �j c�+'�fS . � � � w� � z p m C < �,y r-�-' m A�� ^ � -��C p N9�C M � 6 � �O� 0. NO �SQ' � C"' Q� �� "� � �� C�! Q�