Nelson, Steve NOTIC� OI' CLf1IM I�'a►RM to the City of Saint Paul, Minnesota
�V?irutesu�u Slule S�rNnte�{66.U5.sta(c�.s[hui " ...everv pc�-.san...w/ru<�lui�n,s dunmge.s Jinm anv ntru�icipulr(>>....rhull cuuse ta he pre.crnrecl to rlre
�oi�erriing��ody��f'[Ite mtuiicipnlitv wilhra /RO�Icn�s u�ter rhe allr�ed ln,ss or injury is disc•urerc�/u�rntrc�e stutin��tlic tinu�,plure,und
ci��rums�uiu�es tl�erc n�; u�rd dre nmowu n/'cun�per�.criiirnl��r o(h�r reli��jdc�mandnd.„
Piease eomplele this form in its entirety by clearly typing or prinlin�your answer to each question. If more sp��ce is
ncecled,uttach acldilional sl�e�ls. Please note that you will not be contacted by telephone to daril'y unswers,so provide.�s
much inform��tion as necessary to expl�in your claim,�nd the amount of compensation being requested. Yo�a will receive��
written acknowled�;ement once your Ii►rm is received. 'Che process can take up to ten weelcs or lon�;er clependin�;on Uie
nature of yoi�r cl��im. '1'his fc►rm must be si�ned,ancl both p��ges completed. If something does not apply,wrile `N/A'.
SEND COMPL�'1'I±.D FORM AND OTH�R DOCUM�NTS TO: CITY CLI�,RK,
15 W�S'r I�rLLOGC BLVI), 310 CITY FIALI,, SAINT PAUL, MN 55102
1=irst Name _� MicJdle Initial �Last N�une�►�21 ov�
ComPany c�r I3usiness Name . —
Are You an fnsur�ince ComPany? Yes / o If Yes, Claim Number? —
Street A�dresti �� �3 ( ���le '(ve�e LG��
city r�oc� ���' sr�►te M n/ z;� eode����__
D�iytime Phone (�5�1_)3�-�011._C�ll Phone (�) �53- I o�� Evening Telephone (G�)3S3- ��l
Date of Accident/ lnjury or Date Discovered__ � Time �im/�m
Ple�ise st�►te, in detail, wh<<t occurred (h.ippened), and why you are submitting�►claim. Please indicate wt�y or how you
feel the City of Saint Paul or its employees nre involvecl and/or resPonsible for your damages. 0 �� 15 �!
.M c�f �, .,�� .�� �.�,r�„ G s v�u.,�/ �.
r � �� j,n '�'L. � nnc..�T�-� �--v�� )1' w.,_,,S c! I S'v1� �S 2 e;
o �, '$�`
Plense check the hox(es) that most closely re�resent the reason i'c�r completing this form:
❑ My vehicle was c1am��ged in an accident ❑ My vehicle was damagecl eluring a tow
❑ My vehicle was damaged by a pothole e�r condition of the street � My vehicle was damaged by a ��low
� My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City pro�erty
� Other cype <�fi property damage—please specify
❑ Other type of injury—ple�►se specify
In order to process your clai�n��i need to include copies of'�ll �nplic.►ble documents.
�or the claims types listeel below, pleuse be sure to inelude the docu�nents indicated or it will delay the handling of
your clai�n. Documents WILL NOT he returned and become che property of the City. You are encauruged to keep a
copy fc�r yourselF before submitting your claim Form.
O Property clam<<ge claims to a vehicle:. two estimates for the rep<<irs to your vehicle if the dam�ige exceeds
$500.00; or the �►ctual bills andlor recei�ts for the rePairs
O Towing claims: legible copies of any ticket issued anci a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the �amage exceeds $500.00; or the actua( hilis
und/or receipts for the repairs; detailed list of damaged items
O Injury claims: medicul bills, receipts
O Photographs are always welcome to docu►ne�nt and support your claim but will n<�t be returned.
Pa�e 1 of 2—Please complete and retorn both pages of'Claim Forin
1�'ailure to complctc and return bulh pa�;cs will result in dcl�y in thc handlin�;of your claim.
All Claims— plcasc complctc this section
Wcre there witnestics to the incidei�t? Q No Unknown (circic)
Provide th�ir-i�ames, �iddresses and telephone numbers: ��s G L, E a�,�, o '� 33f 'Eq�f� �'Y��e �,.,,.�
_�,.��.:,! ����_ ,�„��,si�<< <��a_- �56— �a3s -
Were the police o1- It�w et�f��rcement cailed? � es No Unknown (circle)
[f ycs, what dcpartment or agcncy?__�j_�� i p� Case#ur report# �/�
Where did tl�e accident or injury take place'? Provide st�reet acldress,cross street, inteisection, name ol'p�irk or facility,
cf sest landmark, etc. Please he as detailed as possible. If necessary, attach a diagram. C4,r �,.��5 ��c-.N��
o/'� �c f✓1L� "�� L i�d`�-� -�l Y 2(�'� `7 S w�t)-2.
Please inclicatc the amoun�you are seekin� in com�ensation or what you woulcl like the City to do to resolvc this claiil�
fo your SatiSf�►ctic�n. C�.n ;� �� '� L.c? '�:...1 • ��f v� )q . `C
Vehicle Claims—please complete this section ❑ check hox i�f this se:cti�m d��es not apt��v
Your- Vehicle: Yeai- Makc �Mode]
License I'late Number State Color
Registered Owner
Uriver of Vehicic
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Namc)
Arca Damaged
�ury Claims— please comPlele this section ❑ chech box if tl��iis section docs not u�ply
How were you injured'?
What ptu�t(s) of your body wcre injtn-cd? __
I Inve you soubht meeiical �I-eatment? Ye�s No �''lanning to Seek'I'reatinent (circl�)
When did y��u receive treatmei�(? _ --(provi�ie date(s))
Nume ol�Meclical Provider(s):
Address Telephone
Dicl y��u i��iss w<�rk as a result of your injuty'? Yes No
When dicl you miss work? � (provide date(i))
Ivaine of your Fmployer:
Adclress Telephone
�Cl�eck here if yuu are attaching more pages to this claim form. Number of additi��►nal �a �es
I �, �•
I3y sig�zi�cg t/iis forni,yoi� are stati�ig tlaat all infor�natioi�i yo�c liccve provided is trr�e and correct to tlte hest
of yozcr knowledge. Unsignecl forms will not be processed.
Submittirig a false clainz ca�t result itt prosecutioit. Date f'orm was completed � ��� � a c I�
I'rint thc Namc of the Ycrson who Complcted this I�'orm: <�•�-e�2 � Ne 1.5��
Si�;nature of Pcrson Making thc Claim: ���—� �-
Revise�l Fchruary 2OI 1
� RECEIVED
a�� �0 20�4
CITY CLERK
Saint Paul Police Impound Lot, 830 Barge Channel Road, vehicie Release Form
Make: 09 TOYOTA License#: 5�1 EVZ CN: 14008439 Invoice#: 25709
Date/Time Released: 01/15/2014 19:15 Tow Charge: $ 123.95
� Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: ANGIE Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
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: $ 219.50
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 f�ROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature _ si2000
II
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VjSp EntrY Meth�:�' S�iped
iotal: � 219.5E
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STATE OF MINNESOTA DISTRICT COURT
COUNTY OF RAMSEY O RD E R SECOND JUDICIAL DISTRICT
TO REPORT
CITY OF VIOLATION FILE NO.
ST PAUL 620900202800
� DEFENDANT DEFENDANT'S PHONE NO. l
I Steve Nelson 651-353-1011 �
YOU, THE ABOVE NAMED DEFENDANT, ARE ORDERED TO APPEAR ON:
Aug. 20, 2014 at 1 :00 p. m. for Court Trial before the presiding judge in room# 130.
FAILURE TO APPEAR FOR A SCHEDULED COURT APPEARANCE IS A CRIMINAL OFFENSE
UNLESS FAILURE TO APPEAR IS DUE TO CIRCUMSTANCES BEYOND YOUR CONTROL.
FAILURE TO APPEAR FOR A PETTY MISDEMEANOR COURT TRIAL CONSTITUTES A PLEA OF GUILTY
UNLESS YOU APPEAR WITHIN 10 DAYS AND SHOW THE FAILURE TO APPEAR
WAS DUE TO CIRCUMSTANCES BEYOND YOUR CONTROL.
FAILURE TO APPEAR MAY RESULT IN A WARRANT FOR YOUR ARREST
� St. Paul Courthouse...................................................15 W. Kellogg Blvd........St. Paul .........55102..... (651) 266-8180
❑ Ramsey County Law Enforcement Center................425 Grove St.................St. Paul .........55101 .....(651) 266-9696
❑ Maplewood Branch ....................................................2050 White Bear Ave....Maplewood....55109.....(651) 266-1999
DEFENSE ATTORNEY PHONE NO.
DATE February 10, 2014 JUDGE: Handed to the defendant by MA
comments: deft requested court date-Deft handed rights and responsibilities sheet ma
GITATION �3� ��� �
' State of Minnesota Ramsey District Court �
i
city of _ �
; Citation# I IIIIIIIIIII IIIII IIIII IIIII IIIII IIIIIIIII)IIIII IIIII IIIIIIIIII IIII III) �
620900202800 620900202800 �- �
�L Number State j
❑MN ❑CDL ;
Name '
i
First Middle Last i
Address— Street, Apt#
-_ i
' City State Zip �
DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity �
Vehicle License No. Plate Year State Make Type Model Color !
_ � , , '.�t � _. �
Date of Offense Time of Offense ❑AccidenUCrash �
, �� - } ❑Properry ❑Injury ❑Fatal ❑Pedestnan /�y �
M•
Parking Meter Number Neighborhood Code ❑ Housing/Building Code N �
� i
s
❑Booked ❑Park/Operate ❑Owner ❑Passenger ❑Driver � r
Offense Location �
Statute/Ordinance � �
No 1 Offense � '
i
� i
NO 2 Off@fiSe StatutelOrdinance O j
i
� i
No 3 Offense
Statute/Ordinance �
�
❑Speed 169.14(subd ): mph zone p
❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) ;
AC Taken—AC: Test type: ❑ Refused ❑ Breath ❑ Blood ❑ Urine !
,
❑Hazardous Material (DOT) ❑Unsafe Conditions ❑School Zone ;
' ❑Endangering Life & Property ❑Work Zone ❑Commercial Veh. DOT# �
Identification: ❑DL ❑DUS Web ❑ Photo ID ❑Other i
See back of citation for information on paying your fine. !
If cited for No Proof of Insurance or No Driver's License in Possession, Proof of Insurance and/or i
Drivers License must be shown at one of the Violations Bureau locations listed on the back of this
citation within 21 days from the date the citation is filed with the Court. '
i
Please read the back of this citation carefully and respond. �
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Officer(s)Name(s) ;
Officer No(s). r CN# , - Citing Dept: .� . �
How Issued ❑in Person ❑Mailed ❑Left at Scene �
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DEFENDANT I
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