Mickelson, Meta NOTICE OF CLAIM I'�RM to the City of Saint Paul, Minnesota
h9i���re�s•ola Slute Stnn�te 466.05 smtes thcli "...everv persnn...whn clnims dcima�e.s.%rom�rrv municipnfity....cliull cm�.sP m he pre.ecntrd tu tlie
�overnirzg buclv qJ't/re mu��icipc�liry N�i�/�ijt IRO du>>s nfter d�e a//e�c�d/n.ss or injurv is discvi�ered a nolrce stnti�tg dte tinte,��lace.anr!
circaunstcrnces tltereo%and 1he umo�uit of compensntion nr other relie/'demanded."
Please complete this ti�rm in its entirety by clearly typing or printing yc►ur answer to each question. If more space is
needed,attach additional sheets. Please note th.�t you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the�mount of compensalion being requested. You will receive a
written acknowledgement once your form is received. The process c�n talce up to ten weelcs or lon�er depending on the
nature of your claim. This form must be si�ned,and both pa�;es completed. If something does not apply,write`N/A'.
SEND COMPLET�D FORM AND OTHER DOCUM�NTS TO: CITY CL�RI�,
15 WEST K1:LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
Fi►-st Name�� Middle Initial �L�►st Name/`"I �� ��)Ol�l
E-e,rnpany or T3usiness Name � �
Are You an Insurance Company? Yes, Nc If Yes, Claim Number?
Street Address � ���� �
City� �� � State / 'l� � Zip Code ��� lJ
Daytime Phone ( �-`�--Cell Phone ((�J1) ` � C.E.��OEvening Telephone(--�)— -
Date of Accident/Injury or Date Discovered `� u Time �'l. a m
Pleuse state, in detail, what occurred (Y�appened), and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for y ur dam< es. �� �'4-
1 _ —
r � � ��
� �'' T _ S ! ! `� 0' — °
� closel re resent the re�son for com letin this form:
Please check the box(es) that mo,t y p P �
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a row
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was dam�iged by a plow '
�My vehicle was wrongfully towed �►nd/or ticiceted ❑ I was injE►red 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 inclucle copies of all �pnlicable documents.
For lhe claims types listed below, please be sure to include the documents indicatecl 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 bilis and/or receipts for the repairs
�Towing claims: legible copies of any ticket issued and a copy of the impo�md lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
�ind/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 relurned.
Page 1 of 2-Please complete and return both pages of Claim rorm
Failure to complete and return both pa�;es will result in dcl�y in the l�andling of your cluim.
All Claims-n�casc complctc N�is scction
Were there witnesses to the incident`? Yes No �known (circle)
Provide thcir names, addre�ses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If ycs, whnt department or agency? Case#or report#
Where did [he accident or injury take place`? Provide stree[address,cross street, intersection, na f park or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram.
Please indicate the amounC you are seeting in compensat�ion or what you would like the City to do to resolve this claim
to your satisfaction. ��,�� .c,�
Vef�icfc Eiaims-�t�se complete this sectiorr ___ _ _�cl�eeic Hc�x if 41i�;-;�eetiui� ck�e��ic>t �l-y -
Your Vehicle: Year Make Model
License Plate NumUer State Color
Registered Owner
Driver of Vehicle
Area D� aged
City Vehicle: Ye�ir Make Model
Licei�se late Number State olor
Driver of Vehicle (Cit �i loyee's Name)
Area Damaged
Injury Claims-ptease complete this section ��check box if this secti4n d<�cs not a�ply
How were you injured?
What part(s) of your body were injured?
Elave you sought medical treatment? Yes No Planning to Seek Treatment (circle)
When did you receive treatment? (provide date(s))
Name oi'Medical Provider(s):
Address Telephone
Dicl you miss work as a resuit of your injury'? Yes No
When did you miss work? (provide date(s))
Name c f your Fm�loyer: ------- - ------ __
- - - - -
Address Telephone
❑ Chcck here if you are attachin�more pages to this daim form. Numbcr of additionai pa�cs
I3y sig�zing t/ais form,you are stating tlrat ull informatiorz you have provided is true and correct to t/ce be.rt
of yotcr k�towledge. Ufzsigned forms will not be processed.
Srcbmitting a false clairn cu�a result irz prosecutio�z. Date f'orm was completed ��� ` 7"
Print the Name of the Person who Complete this Forn�: ,
Si�;n:�ture of Ycrson Nlakin�the Claim:
Revised February 201 1
Qus �2 ����
CITY CLE�K
i
To find out if your citation is payable without a court appearance,how much to pay,or to pay
your fine,choose one of the following methods: , �c�-�
• Online: Access 2ndwebpay.courts.state.mn.us `� ( `'�� ��vL�
• By Phone: Call 651-266-9202 j��
'You will need your citation number-VISA antl MasterCard accepted.'
• Mail Payments To: Ramsey District Court
Traffic Violations Bureau
15 West Kellogg Boulevartl-Room 1?0
St.Paul,MN 55102
i`�lake checks payabie to: Ramsey District Court �
(A charge of up to S30.00 will be assessed on all returned checks) '�
__._ _ __ - ----- _-------- -- _:
�
Viola' s
St. Paul Courf, Suburban Court Law Enforcement Center
';;W. Keliogg Blvd., Rm 130 2050 White Bear Avenue 425 Grove Street
St. PauL MN 55102 Mapiewootl, MN 55109 St. Paul, MN 55101
0 0 AM- . o - oing Holidays)
Hear;ng�fficers-6;appointment 2) � ��,1,.1����
�
P�ymeni and Penalties
If you wish to plead guilty and submit payment for the offense(s) on the reverse side of the citation,you must
do so within 21 tlays from the date?he citation is filed with trie Court. It is your responsibility to present your
payment in a timely manner. Please allow 5 business day�fo� processing.A$5.00 late fee is atltletl to all
unpaid fine balances.After 40 days from the date the citation is filed with the Court,an adtliiional delinquent
__��_may be added to aC unpaid fine amounts. •
Additional Penatties may include: 1) refsrral to the Department of Public Safety for drivers!icense suspension,
2) referral to a collections agency,and/or 3)arrest warrant issued.
If th2 offense is a petry mistlemeanor,failure to appear�Nill be considered a plea.of guilty antl waiver of the right to
trial unfess the failure to appear is due to circumstances beyond the person':�control(M.S.169.91)and!M.S.609.491)
� C � V � ��
(7 Appeal
To pleatl not g�Alty, or io plead guilty and offer an explanation,take the following steps:
1)after 10 business da - 6-9202 to confirm that the c'tation has bEen filed wiih the Court,and
2) re u icer appoin me .. I with you when me,�ing with a Hearing
er. ����
_ �� �� �� ��,� _ �� �
, �.� �...
I understa b payina!his fine I am entering a plea of guilty to ti�is o se(s)and voluptarily waive the
following rights ta' ���}-�- ���
a. a tnai to the court,if offen�`s��s`��le��eaticU - r ���� t
b. a tria�to the court or to a jury of 6 persons,if the offense is a misdemeanor, ��t
c. representation by counsel,if the offense is a misdemeanor,
d. a presumption of innocence until proven guilty beyond a reasonable doubt,
e. confront and cross-examine all witnesses against me,antl ���
f, either remain silent or to testify in my own behalf.
I also understand that if this offense is a petty misdemeanor,the maximum pos ' e s ntence is$300.00;.��
if this offense is a misdemeanor,the maximum possible sentence is a$1,000.00 fine and/or 90 days imprisonm�nt.
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: ���'�>,��
, CIT�►TIOI�
i State of Minnesota Ramsey District Court
� City of
' III�IIIIIIII��III�I�IIIIIU�NII�II��� ��
� Citation#
;
620900203913 620900203913
DL Number State
❑MN ❑CDL
' Name
�( First Middle Last
Address— Street, Apt#
City State Zip
;
DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity
Vehicle License No. Plate Year State Make : . Type Model Color
Date of Offense Time of Offense ❑AcddentlCrash
, ❑Properry � ❑Injury ❑Fatal ❑Pedestnan �
Parking Meter Number Neighborhood Code ❑ Housing/Building Code N
�
❑Booked ❑Park/Operate ❑Owner ❑Passenger ❑Driver O
Offense Location � Q_.�_
- — N
No 1 Offense Statute/Ordinance 0
. W
No 2 Offense Statute/Ordinance �
W
No 3 Offense Statute/Ordinance
:
❑Speed 169.14(subd ): mph zone �
❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) i
AC Taken—AC: Test type: ❑ Refused ❑ Breath ❑ Blood ❑ Urine
❑Hazardous Material (D0� ❑Unsafe Conditions ❑School Zone ;
❑Endangering Life & Property ❑Work Zone ❑Commercial Veh. DOT#
Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other �
� See back of citation for infarmation on paying your #ine.
If cited for No Pra4f of Insurance or No Driver's License in Possession, Proof of Insurance and/or
Driver's License must be shown at one of the Violations Bureau locations listetl on the back of this
citation within 21 tlays from the date the citation is filed with the Court.
Please read the back of this citation carefully and respond. � {
�
1
i
�
Cficer(s)Name(s)
Officer No(s). CN# Citing Dept
Fipw Issued ❑In Person ❑Mailed ❑Left at Scene
DEFENDANT
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