Rogers,MaryAnn I
. Kl��:�i�'�U
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�UG 0 6 2�1�t
NOTICE OF CLAIM FORM to the City of Saint ��l���ta
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 clays after the alleged loss or injury is discovered a notice stating the time,place,arut
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. ff 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 V�EST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name Q�'`' �� Middle Initial Last Name�V' � �
Company or Business Name
Are You an Insurance Company? Yes��o If Yes, Claim Number?
Street Address �����lr'�E=i`7!� �
City I°'` � .c_�l"ct' �� State � Zip Code,,��
Daytime Phone(6��)�-.��Cell Phone ( ) - Evening Telephone((nS�)77a-���o
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 yo��
fe.;; the�ity f S 'nt raul or its employees e involved or responsible for your dama s./� St'!l��.Cx��
„ , ' L°/'� Ca�i^ �/
� G�e � a
�
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y � �J/�
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
%��y vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
y 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 aze 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
$S,Q0.00; 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
i
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—ulease complete this section
� Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of pazk or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram.
Please indicate the amount you are seeking in compens tio or hat you would like t City t �lo to resolve this cl 'm •
to your satisfaction. �Gt — ! �
��,-��---�-�-��,� `
Vehicle Claims—alease complete this section ❑ check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
dr:��:ry �taims—ulease comnlete this section ❑ 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 addiNonal pages
By signing this form,you are stating that all information 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:
Signature of Person Making the Claim:
Revised February 201 1 �
i ��
� CITATION � ���
� Stete of Minnesota Ramaey District CouK
�
; ��� , � �;,. E,
i Citation# I�IIIIIIIIIIIIIIIIIIIIIIIAl11Il
hi�IIIN�III�III IIIII 11111 II�illl
; fi20900204889 szosoo2oasss
� DL Number State
� Name
❑MN ❑CDL
� Frst Middle Last
� Address—Street, Apt#
� ��Y State ZiP
i DOB(mm/dd/yyyy) Eyes Height Weight Sex Race Ethnicity
I
I� Vehicle} �cense No. Platet Year State Make Type Model Color
i..�J�E�� GK'..;i` �4�� ' S� L,.�.:��.q ka !->',,�+10 �4� `�..V ,�y.-
� Date of Offense Time o(Off�nse ❑AopdentlCrash
`'-, � � �? , � ❑Property ❑Injury ❑Fatal p PedesMan
; Parking Meter Number Neighborfiood Code �;HousinglBuilding Code �
; �
� _� ❑Booked G3`'P�rl'Operate ❑Ownef/ ❑Passenger ❑Driver �
Otfense Location �
g �a -,
_ �`r�.. #��;s i � �'4"�,',.� ( �',.�e��`; �V
; No 1 Offense \�. ���„�„�� �
�. Y � .. . �v+�+"
i .,� � 4 - ' �i 43€" ' ;1 x.., :.� f`ti_, i M
; No 2 Offense � � s�eane�„ar,ce�� •�
I
; No 3 Offense s��n�ora;,,ar�e �
�
❑Speed 169.14(SUbd ): mph zone
i ❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2)
� AC Taken—AC: Test type: ❑ Refused ❑ Breath p Blood � Urine
; ❑Hazardous Material (DO'� ❑Unsafe CondiUons ❑School Zone
❑Endangering Life& Property ❑Work Zone ❑Commercial Veh. DOT#
( Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other
•. See back of citation for information on paying your fine.
' If cited for No Proof of Insurance or No Dmrer's License in Possession, Proof of Insurance and/or
� Driver's Ucense must be shown at one of the Viola6ons Bureau locations listed on the back of this
C citation within 21 days from the date the citation is filed with the Court.
! Please read the back of this citation carefully and respond.
i
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� Officer(s)Name(s)
I
i Officer No(s). =� : �` CN� $.; } i'y Cfting Dept- ;
';�', , � x.:�-,?
� � How Issued ❑In Pe�son _ ❑Mai7ed ❑Left ffi Scene ,
� . . ,
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DEFENDANT �
.....,
- _ - -- -- __ �—` � _ . �
R�CEIV�D
AUG �5 2014
CITY Cl.ERK
Saint Pau�Aolice Impound Lot, 830.Barge Channel Road, Vehicle Release Fo�r�m
�
Make: License#: 044CM6 CN: 14008439 Invoice#:25516
Date/Time Released: 01/15/201414:52 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: RACHEL Tax: (7.625%) $ 15.55
I the undersi ned have recovered the vehicle described above. Subtotal: $ 219.50 1�
, 9 ,
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 PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5/2000
Signature
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