Kruger, Jennifer ���;���/��J
JUN262014
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�x�,o���K
�Ylinnesotn Stcue Statirte 466.0�stntes thnt "...eve»�person...rvho claims dnmages fi•onr ruiy mLUiicipaliz��...shal(cnuse to be presented to the
gover-�iiri�body of dze naiu�icipalit}�ivithin 180 dnys nfter tlze nlleged Ioss or injin��is discoi�ered a notice stating t72e time,place, orid
circw�istnraces thereof, a�id t/se nn�om2t of co�npe�isatiora o�-othe�-relief dema�ided." �
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 3�our 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 `NJA'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name�lU 1n �i� Middle Initial � Last Name /�-r�,(G�1�
Company or Business Name
Are You an Insurance Company? Yes/� If Yes, Claim Number?
Street Address `'C��� I v 1�JC{ �� �'l��i
City � �4� {�l-QG{�Y�v� S State rn�v Zip Code �J�� 1
Daytime Phone ( ) - Cell Phone (IU�Z��� - ���veninQ Telephone( ) -
Date of Accident/Injury or Date Discovered _ '!I I ZS J�� Time�!� am pm
Please state, in detail, what occurred(happened), and why you are submittin� a claim. Please indicate why or how you
feel the Citv of Saint Paul or its employees are involved and/or responsible far your dama�es.i�►,��n.sor�
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Please check the box(es) that most closely represent the reason for completing this form: �c--f�t,��`� �,t,�21?� -f a C�,,�
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow-�p-{���}-
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow�-j'(n�,-��{�-
�2y vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property-f� �'-1'VIQ.Vr
❑ Other type of property damage—please specify 1,(�Lt,1YQG(, C�
❑ Other type of injury—please specify ��X�}t.�,.( �QYt
�-�o Vu.e . 101'�(�
In order to process your claim youu need to include copies of all applicable documents. SCk Gt,'�Gl�
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For the claims types listed below, please be sure to include the documents indicated or it will delay the handlin�of ce.k�aK
your claim. Documents WILL NOT be returned and become the property of the City. You are encoura�ed to keep a Cq vef�
copy for yourself before submitting your claim form. �C W�,t� -{�.tj�PS
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damaQe exceeds -�1�u�
$500.00; or the actual bills and/or receipts for the repairs tsce,(.5o �G�o�e��
�Towin� claims: legible copies of any ticket issued and a copy of the impound lot receipt t?�� '��-��'
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills"�'�'n�
and/or receipts for the repairs; detailed list of dama�ed items c.�'� � t�(ltY'CCC�G'S `���
O Injury claims: medical bills, receipts V14,�.�UY�I-e- Ull�kr^���YIS .��1�YC�
�Photoaraphs are always welcome to document and support your claim but will not be returned. ��U.����
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Page 1 of 2—Please comp�ete and return both pages of Claim Form � �Y�,��y,�.
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IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII INCIDENT INFORMATION REPORT 5/21/20141
STATE OF MINNESOTA
COUNTY OF RAMSEY
DISTRICT COURT
;� ' INCIDENT AND CITATION INFORMATION
�. INCIDENT ID PAYMENT PLAN CITATION NUMBER
2819039 620901514602
DEFENDANT NAME JENNIFER LEE KRUGER
ADDRESS 4118 NICOLLETAVE
-- MINNEAPOUS MN 55409
DEFENDANT INFORMATION
DATE OF BIRTH 5/14/1983 GENDER FEMALE
HEIGHT EYE COLOR
WEIGHT Dl_NUMBER A�6102504�6�2 DL STATE MN
R�CE HISPANIC (Y/N)
OFFENSE INFORMATION
DATE/TIME 04/25/2014 07:49 DIVISION RAMSEY COUNTY
LOCATION IOWA AV E AND FLANDRAU STCOMMUNITY ST PAUL
AGENCY ST. PAUL POLICE DEPARTMENT
METER ISSUING METHOD LEFTAT SCENE
OFFICER 1 27510 CN
OFFICER 2 NBRHOOD
VEHICLE INFORMATION
PLATE 770EGT MAKE CHEVROLET
STATE MN MODEL IMPAL
PLATE YEAR QOLOR BLUE
VEH TYPE PASSENGER VEHICLE V'IN 2G1W658K081237376
` VEH YEAR
RESPONSIBLE PARTY ID METHOD
NONE
CHARGE INFORMATION STATUTE/ '
STATUS REASON JURISDICTION ORDINANCE DESCRIPTION
CLOSE OTHER STATE OF 169.34.1.a.15 Stopping/standing/parking where�igns prohibit
, MINNESOTA stopping
ORIGINAL FEE INFORMATION AMOUNT DUE
$20 FINE 20.00 $20 FINE .00
LAW LIB PARKING 3.00 LAW LIB PARKING .00
Srchrg-2nd District 1.00 Srchrg-2nd District .00
Srchrg-Parking 2009 12.00 Srchrg-Parking 2009 .00
GRAND TOTAL 36.00 GRAND TOTAL .00
:: OFFICERS COMMENTS
�::?. NO PARK ZONE 7AM-3PM APRIL 25. AUTH NUMBER 9206
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 08 CHEVROLET License#: 770EGT CN: 14078568 Invoice#: 150300
Date/Time Released: 04/25/2014 09:28 Tow Charge: $ 60.00
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: CHERI Tax: (7.625%) $ 10.68
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 150.68
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: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 150.68
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 RIGHTS, REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature 5i2000
� - � �`�
RamseY District Court
State of Minnesota
CITY OF SAINT PAUL
PARKING CITATION
citation No. 620901514602
Cae�No.'. i
g�paul pollce DepaRment -_
Vehicls Licsnse Number�.
770EGT sc■u:MI�VSA
Vshicls VIN: Color:BLUE
Maks:CHEVROLET Model-.�MPA�A e ppSSVEH
Typ
Tab Yea�:
Tab Month: Time of Offense 07:49
Date of otfense 04�25�Z014
ORense �
StaWtslOrd �
�gg.34.1.a•15 PARK wHERE SIGNS PROHI8IT
plfsnss Location:
-�pWq AV E Intersectlnp StresY.FLANURAV s
2nd Cross Street�.WHITE BEAR AV M
Oltenae City: S�9ny Vis�.
St.Paul permit Zone: Time Zone'. .
Meter Number: Chelk Out: Parked. (HH:MM)
Chalk In'.
Unit:�Z
�aficer 1:PEO L.Ayers
'�?lficerNumbec 27510
om�.r z: .
plficer Number:
RepoR defective meters by noon the next business day
Call(651)288-9778
•�our flne b`85P,28B g202aft 5 business days and then call
4
,r No DQf�he Violatians Bureau Locatona ifeted bslow withinor
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