Soukhanov, Anton . --�- . ��c�iy�D
NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso�a�14
CITY ����,t�
Minnesota State Stalute 466.05 sta�es that "...every person...who claims damages from any municipaliry...sha/l cause to be pr s
governing hody of t/2e municipnliry wit/zi�i 180 days nfter the ulleged loss or injziry is discovered a notice stating�lze time,place,nnd
circumsrm2ces thereof,and the amount of canpensation 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 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 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, SAINT PAUL, MN 55102
First Name �✓'��r Middle Initial�,Last Name������'1p "
Company or Business Name
Are You an Insurance Company? Yes/ o If Yes, Claim Number?
Street Address y �1�.- �/�� vY�
City ���� State �� Zip Code �r/Z 3
Daytime Phone(�/L)�[/l L� Cell Phone �7-)��L`�Evening Telephone(G�Z )�-�y��
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 employees are involve and/or resppn�sible for your damages. .��a1 -�/[/�l��c.�
sX /ie r��.' '�r�% �r[�C. ,� � �'
r � „,, sc. hy - �
/' �.. L.�ct!' v� �'p�c� /'0 I a � �
.
�/ .
� �-� ✓�r�S,L[
_ r t ,
3 7)�✓ho
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
�NIy 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 ue 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
Failure to complete and return both pages will result in delay in the handling of your ctaim.
All Claims— lease com lete this sectio
Were there witnesses to the incident? Yes No ( rcle)
Provid� eir n�ames ddr sses and tele o numbers: �2✓1Vi
1 �a 7 t, ,� l� s� ��I T 3 s s zn
Were the police or law enforcement called? Yes No Unknow (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address, cross street, intersection, nam of p k or acilit ,
close t lap�m rk,etc. Please belas detailed as ossib e. If necessary, attach a diagram. l,v4S� � �l-, ��
� �� � , � �, � �� s�� s
, Please indicate the amount you e seeking in compe sation or what you ould 1' the C'ty to d to eso ve this c �rn
to your satisfaction Q, � �
�, Q /' � �
Vehicle Claims— lease com lete this section ❑ c eck box if this section does not a 1
Your Vehicle: Year��Make � odel , O
License Plate Number �J.✓9�1 S te Colo
Registered Owner v►�C�
Driver of Vehicle .� ��' rr�
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims—please complete this section ❑ check box if this section does not applv
How were you injured?
What part(s) of your body were injured?
Have yoa sought me�ic;.l treatmen[? 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:
Ac�dress Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages j .
By signing this form,you are stating that all infornaation 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: �� �� np
Signature of Person Making the Claim: �'
Revised February 2011 �
S��nt P��I PaEir„e [rrtpcau�d L�t, �{� B�rg�Ch�rtr�e� Rt��, V�hicte Rel�as� Forrn
Mak�; 98 BI�+IW Licen��:XC1�45 C�I: ���#97�J3 ln�rc�i�c+e�: 15{f66�
C3at�ITit�e ReE��s6d. i?s12�fl14 12.t�� Tsn�►+Ch�rge;: � 6{).t� ��
R�6���+d h�;TC�TO S#t�r��e Ch��e: � {3��0 �
P�id t�y.�A�Fi Acimin�h�ge: � 8�.t�p
Fteiea�cf by: �Vl� Ta�t; (7,���'ti�� � 10.�8
l.the urrdessig�ett,�t�v�t+e�++�r�+si the v�#t�e ttes�it'�at�arve. �ubtt�t�f: � 1�,�s8
1 wif!c�'�+€�s t��v�hi���` ��or arr���r pr�blerr��tir�t
m�p l��ve r�ccurr��e�whi�#t��ve�icl�was i►�t�e e�stcxPy pt the S�t�rice�h��c��: � t��Utl
Saint�au�Pc�ir���rr��t. 1 a�tnc� y�t vu�ft�p!�rk
dam�e ar�tvc any at�er�'r�b[�r�s�o the i�ttd Lo#sta�f Fcstal Charg�' � 15t�.�
�r� ���f pr�qr#����v€ng�he it�t�u�c�it�t
L��� �r��lar t�ttt� _ m.
Pal'i��Ft n���: ��:,,,�..,hl�,�!F�����d A If t�C).'���'
T4 PR�'���T YC�IJ� �IGMTS F��P4RT,4td'Y PRC�BL��Sli��Nta4��B��C1E�E L�A�/IN�G TH��{��'
�'sgnat��
�
4/2/2014 Dept of Public Safety-Dri�er and Vehicle Ser�ices
� :
�'�f Driv+�r and Vehicle �ervi�es
Exit
Confirmation
Please keep a record of your Confirmation Number, or�rint this oaae for your records.
Confimiation Number MNSDVS003263546
-.��.� .�� " �ii .
Description MN Department of Public Safety
Online Renewal Services
http://www.dps.state.m n.us/dvs/
Payment Amount $49.15
Payment Date 04/02/2014 �-• � !�� �N �J P✓1 �G�l-s � �.K- (��'�--
Status PROCESSED ��,/��1 -� �/�//l� ����j�'� � �iC�j„1,
�` !'�.C./
t I.� .[" . . , e
i
Payer Name Anton Soukhanov
Card Number *8147
Card Type Visa
Approval Code 087726
Confirmation Email antonsoukhanov28@gmail.com
a .:
Address 1 1144 Blue Heron Court
City Eagan
State MN
2ip Code 55123
https://epayrnerrt.epymtseruce.corri/maiNpayrnentconfirmation/pa�tCa�firmation?id =142-64AD766F5EA2E2E43F41E1E93525E326 �/�
i
i
i _ __-- - --- - _. __ _ ____ _ _` -- _ ___ ,�
� ���� j
_ -- - -- _ _ _
� � - �
_ - -- , �.- - �
_
�___ ___ l-� - �������--� - c.��-�.� - ��-��� : . _
1 � � �,
. �,�J
� �'�.!�„}--k �'-'�'��l- ��'��i - -"� �'�`-crL ,f_ � �'�L� _ _
_ _____ _ -- _ _ _ �
° 1 ,�
-
�
_ _
--_ _ _ ;- -%�-= - __ ._ _ ?GC,��C��; -- —C��%��-�-_ - �=c�r:i .: C� t_.-, __ _
,
' ,��_ � ('%�"��. t-�-� �-� �,
' ��,� �`� -� __ _ �� _��� �.�
�
. ; . _ � ,
- _ _ _ _t _ _- --- - . .. _ _ __
i . __ : !
_.
J /� /
- �- _ C'�% ��1.���r:.J �'''1`� _ ;�.� __ ___� ���� - - l .
i �
----- __ -�
I r _
., , ^ ' l n
� ,. '
_ __ _ f_ _ ���L ✓� �J ��.�'_�..�-�.�� -._ _�-/� l.t��?c.�G_ . ._ ����-�' __ _
� ��'���°L-�f' _ _�_� �_ �r �� ��' _;� .__��i fµC-C.C!�-(�:�-C�
, _ , _ � _ � t_`
__ ___ _ _ __ � .- ��
, �.
� � /��
_
� ` � , �� z�?'r�-°(" -1 ' , ' __(��(,N""t.}r��
i (;�,�,�� ��'_ 1
_ _ , _ : _ �-- . ___
. � /
_ - . ,
. �
' - �'��L��i � ��_�_ ,-•__. .��t'�Sm __ _� __/c�t� ,�'��-cv� ��?
I �
, �
`' " 'C�"�<,-�.-� t..L �F ._ 1'(� ��f:-�'/' 1�---- - �� _j! _
� 1 .�
�
, �" _ _ ..
..__.-_ _. _ .. _ _. ._. ._ _
.
� :
, � � ,�.
�
�
,
� /� _. ,
� � � x� �t ' t '�
-__-- _ � ,���� ' I���..�. - .`� �; �.��-��.� �, <r'-"t.-� _ �i��--'
_ .
--_ I ��-��,c�� C`'�.'L� � -�`��' _
I / �
__ _ ����` �` � _
� �}� ��,� �,
____ _ _ � ��
, __ ( � ry���- � �-��..��
� < -� _�.
� �,�� , _ c �� . _
_ � � - - � �
i L `� �'� �C� --��" _
_
� �./��-���� —�.�►C�_�" _
�
___ I _ _ _ _ __ _ _
�
�
� _ _
__ _ . . _
� _ _ _
, __
_ ____ � _
__ _ . _
_-_ _ _ _ I _ _ _ _ .
� _ __ ____
--_--__--- __ _ _ _ _ _ _ _ _ __ . ___ _.
t _
f __ _ _ ___-
— ----�----- _ _ . _ ___ --
- _ _ _ ___ _ __ _ _ .
_ __ _ _
�
�
� -- _ ___ ___ _ _ _ __ _ _
--_------ ---_ ---
; _ _ _ _ .
_— ______�_- -t-_ _ __ _ . _
�
- - - _ _ _ _ _ _ _ _ __ _ ___ _ _
�
__ __ _ __ __ __ _
_ _ __ _ _
_ _ _ _ � _ ___ _ ___ _ ___ .____ _
� _ --__ - ___ _ _ _- -- -_ _ __ __ _ __ _
- --- - ----_r _ _ ---- - __ _ . -
State af Minnesdta '
. R��n�'y Disirict Court
�C!TY JF S1��t�v�' FaUL
PARKING CITATIOP� , Y� •� II II I II����
citation No.: 620901496G�5 t �
Ceee No.:
St•Paul Police Departmeht ��.
�
Vehicl�Lic�nse NumbEr: XCW9;�5
Vahlc�e VIN: State;MN USQ
Make:BMW Model:��NO'f�IN LIST
� Color:BLqCK
. Tab Month:8 TYP��PASSVEH
�ateo�Dtfense 05l19/2p74 TabYear:y013
Statute/Ord T�mc of DfFense 2Q;�6
��--_�____ Dffense
757•03.a.20 Stop/siantliparR Veh on�ny��YeeUail---_ey t---ame—j.�--
ocation,for m�re than 48 consecutive hours-
168.09.4 EXPIRED REGISTRATfON
Offense Location:
VICTORIq ST S Intersectinp Street:7 ST W
2nd Cross Street:
� �Rense Clty:
- St.Paui
Meter Number: �
ChalH In: Permit Zone:
Unit:96B Chalk Ouk Sipns Vis:
Parked: (HH:MM) Time
. Offiter 1�pEp g �4�d Zone:
OfficerNumber:q�ZgS�
omco�z: ,
. �fiicer Number:
Report defective meters by noon the next business day
Cail(651)268•9776
T�Pay your fine by credit card,wait 5 business days and then cali
(651)268-9202
If cited f ------�__
. NoProofo(Insuranceor �'----_______
Drivers�icense should be sho N�Drivers License' —
30 business K`��n one of the �n POSSession,Proof of Inaurance and/or
days of the violation. Violations Bureau Locations listed below
. . To pay yaur eitation online� within
� �w�,v.?ndwebe?Y:�ourts.state,mn.us
For additional information or to pay your fine by tele h
Call• (661)266�202.
P ona usinp a credit card,
. � Pleasa have your cltatlon number and credit card avallable.
. Mail paymente to:
� RamaeyDlstrictCourt �
Traffic Violations gureau
- 15 Wey�Kellofl9 Boulevard-Room 130 .
. St.Paul,MN 66102_1613 _ �
. Make checMs payableto: " `f
(A charge o/u Ramsey District Court �
___ ___ p�0 530.00 will be assessed on all raturned checks). .
---��
Violations Bureau Locati----
St.Paul Court ' -"-----
• 16 W�Kallogg Blvtl.RM 130 Suburban Court -���
St.Paul,MN 65102 2050 White Bear qyB, Law�EMO'rcement Center
Maplewootl,MN 66109 425 Grove Street
�ffice Hours:8:00 A.M,_ St.Paul;MN-56101
_ Haaring Officers:B a ppo�Mment�onlaY�Friday(Excluding Holidays) °
' .----. Y a y tall(661).266�202
-_ _
� � ----------�—�_ -
� If you w;sh to piead puilty for the oRe�yment and Penalties —�'----'-
' . within 30 days From tha tlete[he citation�5�on the reverse side o�the cit �
present your payment n a timEl�m�....__��f 1ed W�th thc Cnrn u;..,, ation,you musFdo�,. �
la�..se_:_. .. .