Lee, Kao �EC�l�.��D
� . �
JUL 2 � 2U14
NOTICE O� C�AIM �'ORM to the City of Saint Pau1, 11��S�ERK
Minrzesota Stnte Statute 466.0�states dint "...ever���ersori...who clainxs dnmages fro�n nrry mu�ticipalin�...shall cnuse to be prese�ited to the
governino body of the municipalit��tivithin 1 SO dnys after the nlleged loss or injury is discovered a notice stnting the time,ylnce,nnd
circumstnnces thereof, and the amount of comyensntion or other relief demnnded.°
Please complete this form in its entirety by clearly typing or printing your answer to each question. If inore 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 acicnowledgement 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 �,7i►� Middle Initial Last Name L- e
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address � �0���A i�(1 PXT" S-`' ��'�' �
City �,�_�t A � State �,1� Zip Code��
�i} 7 ��33
Daytime Phone(,��1)�- ub Cell Phone (��� )�°�- ��U Evening Telephone(�_�� -
Date of Accident/Injury or Date Discovered �����...' �`f Time am pm
Please state,in detail,what occuned(happened), and why you are submittin�a claim.Please indicate why or how you
feel the City of Saint Paui or its employees are involved and/or responsible for your damages.
ne�
� �
; ; :� .
�
,
Please check the box(es)that most closely represent the reason for completin�this form:
❑My vehicle was dama�ed in an accident ❑My vehicle was damaged durina a tow
❑ My vehicie 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 type of injury—please specify
In order to process your claim��ou 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 handlinD of
your claim. Documents WILL NOT be returned and become the property of the City. You are encoura�ed to keep a
copy for yourself before submitting your claim form.
O Property dama�e claims to a vehicle: two estimates for the repairs to your vehicle if the dama�e exceeds
$500.00; or the actual bills and/or receipts for the repairs
O TowinD 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 damaae exceeds $500.00; or the actual biils
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photo�raphs are always welcome to document and support your claim but will not be returned.
Pa�e 1 of 2—Please complete and return both pages of Claim Form
I Failure to com lete and return both aQes will result in delay in the handling of your claim.
P P 5
Ail Claims—nlease complete this section -
Were there witnesses to the incident? Yes No Unknown (circle)
� Provide their names, addresses and telephone numbers:
I
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or aDency? Case#or report#
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. l
Please indicate the amount you are seeking in compensation or what yo would like the City to do o resolve this claim
to your satisfaction. i S C7� i�� �rC �- �� 1 wt/�f,��
w4� ;
( (.�4��• � ��
Vehicle Claims— com lete thi ction - ❑ heck box if this section does not a 1
Your Vehicle: Year t� 'L Make Model
License Plate Number State (bl N Color 1��-.�-�
Registered Owner ��1�-0 1,.��-
Driver of Vehicle �-e ]�C�
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims—please comnlete this section l�'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(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 pages
By signing this form,you are stating that all infornzation yozc have provided is true and correct to the best
of your k�ZOwledae. Unsig�zed forms will not be processed.
Sub�zitting a false claiin can r•esult in prosecution. Date form was completed '2��� �'y
Print the Name of the Person who Completed this Form• �b �t�c C
Signature of Person Niaking the Claim:
Revised February 2011
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form {
Make: 02 HONDA License#: NONE CN: 14148894 Invoice#: 151626
Date/Time Released: 07/19/2014 15:12 Tow Charge: $ 60.00
Released to: TOTO Storage Charge: $ 0.00 �p V il
Paid by: CASH Admin Charge: $ 80A0 J
Released by: JAMES 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. 1 acknowledge 1 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
5/2000
Signature
i�rr - --- ____--
a ' MlNNESOTA DEPARTMENT OF PUBLIC SAF �� P�ate I,NII�IIIII�I�II�I� I�II
DRIVER AND VEHICLE SERVICES 128PAK
445 Minnesota Street Saint Paul,MN 55101-5160
' a- Photle:(651)297-2126 i'TY:(651}282-6555 Web:dvs.d �"'Yearv -
ps.mn.gov
APPLICATION FOR DUPLICATE pLqTES ANDIOR STICKERS I
� PLEASE READ�NSTRUCTIONS BELOW BEFORE COMPLETING ' �"�x S6dCef�•� '
CENTRAt OFFICE USE ONLY A Dupllcate Title ls NOT tequbed when api�ing/pr��g(�
CURRENT PU1TE NUI�ER P�t65 olSdiCk�s
VEHICLE IDENT�ICATTON NUMBER
CURREIVT
,` 1 H G C G 1 6 S 4 2 A 0 7 9 1 8 6 °��R"�N onTE
MODEL YEAR n�u►� Ty� ,,,,� �
� 2002 HONDA LIIX _
` � 4 �15
IAST,FIRST ANO MIDDLE
PRINT NAME OF OYYNER(3) ► DRnr�R'S uCENSE NUMeER
L�'�� A 7 4 1 O 9 9 8 O 8 9 I 2
PRlNT ADDRESS� STREET
FIRST OWNER C�N COUNTY STATE Z�p
(PERMqNENTADDRESS) � ISOS KLAINERT ST APT D SI'PAUL �J��. �
THIS APPLICATION IS FOR DUPUCATE(Please chedc a1�at $511
aPP�Y)� �X! PLATES (- YEqR STICKER (-; Y4EtGHT SFICKERS
THE REGISTRATION PLATES,YEAR S7ICKERS AND/OR MON7'H STiCKERS FOR � FEES DUE
TH(S VEHICLE MUST BE REPLACED BECAUSE THEY yyERE(chedc ao y�at appy: I AM REPLACING THE
STIGiCERS FOR THE � ¢
(� STOLEN � LOST DUPLICATE
(-1 DEFECTIVE MONTH OF: b��
�' DESTROYED r SURRENDEREQ (—( NEVER RECEIVED FIUNG �p.�p
r• ISSUED 1N ERROR YEAR OF: ; ¢
TOTAL I1�,OO
MUST BE ANSYYERED WHEN APPLYING FOR DUPUCATE PLATES I(WE),HqViNG BEEN DULY SIMORN,DO CERTIFY ALL OF MY(OUR)DECLARA pN
NAME OF INSURANCE COAAPANY: ARE TRUE AND CORRECT AND THIS VEHICLE IS AND 1MLL CONTINUE TO BE
INSURED WHtLE BqNG OPERA PON THE PUBLIC STREETS AND HIGHW/� $_
- . _ __ �---- _-
_. _ -
_ _ _ _ _ _ - _ _ __ _---- -
POLtCY NUMBER: -` " "
oA.rE 7-I9-[4
OVIMER'S SIGNATURE
�F PL.ATES AND/0R STICI�RS MUST BE SEMT TO A 7EMPORARY ADDRESS,PRINT ADDRESS HERE:
STREET
C� ' STATE Z�+
�
INSTRUCTiONS: PLEASE READ CAREFULLY BEFORE COMPLETING � , ��'
I.Cort�lete this appliption on this side only.PLEASE PRINT OR lYPE. ]���
�� O��
2.Attach this vehtde's cixreM regishation card. �
�can^ot attad►fhe arrent te9�SUation card because it was: r LOST �DESTROYED riNEVER RECENED �N(��
. 7��
[ i am currenty driving outside U�e state�Minnesora and
������t���������� PRORATE CUSTOMERS ONtY:
.'Never Reoeived'applies ONLY to plates andtor s6dcers m�led by ihe pmrer and Vehide Servioes Division_ ���Cab Card Must be Surrendered
Answer:In an attempt to find my plates ar�/or stickers I have coMaded tMe Postai Service: Ci Yes r No UNfi�:
fl yes,when did you caiiact the Postal Service9 20 ACCOUNT#:
.'Surrendered'applies ONLY to plates and/or stickers which were surrendered due to fedc of insurance Coverdge.
To detertnine the fees due or to obNain assistance in canpteBng this application,�nWd:
A DEPUTY REGISTRAR OR THE DEPARTMENT OF PUBUC SAFETY,DRIVER AND VEHICLE SERVCIES DMSION
MAKE REMITTANCE PAYABLE TO:TFIE DRIVER AND VEHiCLE SERVICES DMSIQN
IMPORTANT NOTICE: PIEASE READ
�e rtanth andtor year stk�cers you are repiacing MUST match 1he stldcers originally on this vehide.This application for duplicate qates and/or stidcers must be completed by the
:rson(s)in whose name(s)this vehic�e is now registered,and the registration card end any fert�aining piates and/or stidcers rrnut be surrenderEd b fhe
registrar fot cance�afion.
I data co9ected ai a motor vehicfe appC�catiai are required by law.These data are used to identiy your motor vehide.FaiYre b provide req�ed date may re�i n deriai d tl�e
inster d ownc�st�,regisOraGon of�s vehide or o4her iequested adion.Except fot��uses pertnttted by feder��d sta�e Faws.Pe�ai info�ma6on arNai�ed'n yar�on
ay n�be di��ar�yate�o�N your expre.ss cor�tt
i20678-t5(03H2)
�
Payiess Auto Sales and �epair !
$03 Earl Street V�hic�� P�rc�as� Contract ,
St.Paul, MN S 5 I C5 stock# __ __
Tei: 651-756-7165 _ � �4U�i}' __ __ ,-
f Date: _�_ ��'_!__�_ Saiespers�r�: _� � {•C 1 '�'��!�
�:�yer?ast i��me:--�2�_ First _.__._�Q Mid�ie _ _—T --
�1������: __ t��— 1a� n�r S�'���P`. � � �—
�Y � —��—_ State: M 1tJ zf�: _,��� �
�river's Lic. #_—�I 1� {d� � Q'���p2- _�H: ?����_L��IL��_�s:_� D.0.8.: - j� '���
�o-Buyer Last f�ame: -- _ First -------_�_-- -- ��iddle
'_r:ciress: __ ---- _ City: - --- Staie�_s _ Z�p: ��
=��ive�'s Lic. � - __ PH: Res. �us: D.O.B.:
-----.,_...-
_ien Holder _ Address:
, -- ---
nsurance Company Policy ,# ___ Phone
°iease Erite.r My Cr�er For: NQw❑ llsed;�
!ear A—��_-- -- ` Make C�Y1�� Mode! � C CQ��_ Body � �•
%ir:# �_�f' �"Z����-{�(�� �g�j Lic, # Mileag� �� Coior _��1�
�--------- -- - -- --- — ---- ----m--�-
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INSURANCE IDENTIFICATION CARDS PERSONAL INSURANCE
PLEASE KEEP A CARD IN EACH VEHICLE SERVICE CARDS FOR
DO NOT USE IF YOUR POLICY OR COVERAGE IS NOT IN FORCE YOUR WALLET OR P�JRSE
INSURANCE IDENTIFICATION CARD NATIONWIDE AGRIBUSINESS INS CO
(Minnesota) 1100 LOCUST ST DEPT 1100
KEEP THIS CARD IN YOUR VEHICLE DES MOINES IA 50391-1 7 00
Policy No. PPGM0044837156-0
Account No. 920512233 �r, �
LEE, KAO �
CHANG, YING � N
1505 KLAINERT ST APT D c�
SAINT PAUL MN 55117-5941 ? � � o
Po licy Perio d:1 1 1 1 5 1 1 3 to 1 1/1 5/1 4 T his Car d e ffe c t i v e: 0 7/1 1/1 4 Z � � �
Veh: 4 02 HOND ACCORD EX 1HGCG16542A079186 cW9�o � �
FREEDOM INSURANCE AGENCY INC W q p} a°'
WILLMAR MN 56207-0996 �N �z w ;;
Minnesota Law requires the possession of proof of insurance to be produced upon �� W= W m � y
demand of a peace officer. This card is evidence that security as required by Section : v�Z -�v m� Z E
65B.48 is provided for the insured vehicle. �� ?� �Z y `—°
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Insurance �
,n.uo�.:dr�m�r
a�M.rs4'
INSURANCE IOENT1FtC�ITtON C�'" ` " O��C;121�USINESS INS Cd
(Minnesota) 1100 LOCUST ST DEPT 1100
KEEP THIS CARD IN YOUR VEHICLE DES MOINES IA 50391-1100
�.`
Policy No. PPGM0044837156-0
AccountNo. 920512233 � �
� �
LEE, KAO � � N
CHANG, YING
1505 KLAINERT ST APT D c� ; N N
Z M h O
SAINT PAUL MN 55117-5941 } �M � �
Policy Period:11/15/13 to 11/15114 This Card effective: 07/11/14 W � °o r � �
VOID �`° z �N
Veh: W Q p>' a°'
FREEDOM INSURANCE AGENCY INC Z o �z �
WILLMAR MN 56201-0996 �� �� W g � �,;
Minnesota Law requires the possession of proof of insurance to be produced upon � � m Z �
demand of a peace officer. This card is evidence that security as require d by Section �o ?� �,_�., � '�
65B.48 is provided for the insured vehicle. -o�:� �a p z � v
a�?� W J � C) O =
�
aiied u�.3 ? �a Q tv m
I�surance
.H.uan+ar�.+,.�n
a,w..sir�
IMPORTANT INFORMATION
Every driver and owner must produce an ID card or evidence indicating that the vehicle had insurance at the time of a peace�,of-
ficer's demand. Or, if the driver does not own the vehicle, provide the owner's name and address. If the driver fails to produ�e
such information, or if the owner fails to produce the information within 10 days of receipt of the notice from the officer, ftte
Commissioner of Public Safety shall revoke the person's drivers license or permit for 30 days. (Sections 65B.67, 169.71-169.73.)
It is a misdemeanor(1)to fail to provide proof of insurance, (2)to alter or make a fictitious ID card or other evidence, (3)to display
an altered or fictitious ID card or other evidence knowing or having reason to know that such proof has been altered or is fictitious,
and (4)to issue, display, or cause or permit, or have in possession,an ID card or other evidence knowing or having reason to know
that insurance is not in force. The third violation within ten years of the first two convictions is a gross misdemeanor. (Sections
169.791 and 169.793.)
A person operating a vehicle without the security required by Minnesota Laws Section 656.48 is gui�ty of a misdemeanor, o�C:a
gross misdemeanor if the violation is within ten years of the first two convictions. (Section 169.797)
ID 0022 j05-951 INSURED COPY 920512233 74 3060
DIRECT BILL IyZ9 14194
• CONTROL FEDERALAND STATE LAWS REQUIRE THAT YOU STATE THE MI�EAGE�IN�OkNE_'�71pN WITH THE TRANSFER OF OWNERSHIP.Mh,
NUMBER ' ` ' ' � �,4W REQUIRES THAT YOU MAKE A DISCLOSURE ABOUT DAMAGE TO THE VEHICLE.A FALSE OR FRAUDULENT STA7EMENT OF PU�
_ BY ANY PERSON IS A GROSS MISDEMFJWOR OR FELONY. ' • '
_ - SALES TAX DECLARATION AND FEES
� .... $ a soo REGISTRATION TAX $
FULL PURCHASE PRICE..............................................•-
}'
PLATE FEE
LESS TRADE-IN ALLOWANCE............•--•......................... .
ARREARS TAX
NET PURCHASE PRICE....••..........................°--....._............ •
%OF NET PURCHASE PRICE...................... /� �_
LESS TAX PAID TO ANOTHER STATE.......................•----• ,,
NET SALES TAX DUE $ /��_ PSV FEE � -� '
TRANSFER TAX �
�aoe-�N was a: TITLE/TRANSF , E �.
Q�4
MODEL MAKE PLATE OR VEHICLE I�ENTIFICA'imN NUMBER SALES TAX '
YEAR
Minnesota Deater's License Number. LATE TRANSFER P N
1 DECLARE Minnesota Sales Ta�c Accourrt Number: SUBTOTAL $
THIS TAX
EXEMPTION �ntemal Revenue Code Number(IRC): STATE/DEPU7Y FILING FEE
CODE: �RP Acct Number:
If Leased,Lessee MCDP Nvmber. TOTAL WE $ �}
(�
R E A S S 1 G N M E N T B Y L 1 C E N S E 0 D E A L E R O N L Y 1(WE)CERTIFY THAT i'Hi5 VEHICLE IS FREE FROM ALL SECURITY INTERESTS,
WARRANT TITLE,AND ASSIGN TNE REGISTRATION TAX AND VEHICLE TO(BUYER):
ODOMETER DISCLOSU STATEMENT. I(WE)CERTIFY THAT THE ODOMETER NOW ❑ISACTUAL MILEAGE
READS (NO TENTHS)MILES AND TO THE BEST OF MY ❑�CEEDS MECHANICAL LIMITS OF ODOMETER
KNOWLEDGE THE ODOMET MILEAGE: ❑1S NOT ACTUAL MILEAGE-WARNING ODOAAETER DISCRERANCY
DAINA�E OSURE STATEMENT. TO THE BEST OF MY IQ�VYLEDGE..THIS VEHICIE: I
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DAMAGE D OSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE,THIS VEHICLE:
❑W� NOT(CHECK ON�SUSTAINE MAGE,.EXCLUSIVE OF ANY COSTS TO REPAIR,REPLACE,OR REINSTALL AIR BAGS AND OTHER
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