Erickson, Kevin RE���\.���
__ _-,.�.. AUG �9 2014
1�dOT'I�E OF C�,AIlVI �'O�l� �� the C��y ��' Sain� P��l, �i��e��RK
rYlinnesota State S�atzrte 466.05 stares lhnt "...everv perso�:...who clainu damages from any munrcipality...sha(l cause to be presented to die
gnverning hody of rhe municipaliry widiin 180 days nfter!he ulleged loss or injury is discnvered a no[ice stn[ing rhe rime,p(ace,and
circumstmtces thereof, crnd the amoeuir of compensatioii or nther relief demanded."
Please complete this form in its entirety by clearly typina 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 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 paaes completed. If something does not apply,write `N/A'.
SEND C01l�IPLETED FORM AND OTHER DOCUMENTS TO: CIT�' CLERK,
15 WEST KELI,OGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name'`��'�w Middle Initiai � Last Name �}IC.�CS�v\
Company or Business Name 1"l�
Are You an Insurance Company? Yes No If Yes, Claim Number? _ N �/J,
Street Address Jc��- � � �� �v� N W
City ��ICa�C.C�t. State � � Zip Code SS�U3
Daytime Phone (6�� )7�f�-Sa`�} Cell Phone � ��)�-5�-y� Evening Telephone (763)l5 3_ �S 1�1
Da[e of Accident/Injury or Date Discovered b�g���y Time�3�bG am L{m�
��
Please state, in detail, what occurred(happened), and why you are submitting a claim. Please in�licate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for�our damages. �.� l ��-`,a.v1�
C ' ,I ���e ' -� �
►
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
0 My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
�My vehicle was wrongfully towed and/or ticketed O 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 vou 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 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 bills and/or receipts for the repairs
O 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 Photo�raphs 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
Failure to complete and retui-n both pa�es will res�ilt i�i delay in the�aandlireg�f your clai�n.
All Claims—please complete this secaon . ,� ���`r
Were there witnesses to the incident? Yes No Unkn wn (circle� � ��:��-.���,�^
Provide their names, addresses and telephone numbers: � � � ��i � �.,
-' ��`.
Were the police or law enforcement called? Yes r N� 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 par or facility,
closest landmark, etc. Please be s detailed as ossible. If necessary, attach a diagram. c: �'�c ���
[,� � , ,� � 1 k. IV "
Please indica[e the amount you are seeking in compensati n r what you would like the City to,.do to resolve this claim
to our satisfaction. � 1 . — � ' �� `-
' � � w+ C: - �L. c-�?
���-F
`�'� G e'�-' �t�N ��-�_� .� S U�i 5 f t-z}n `E' ✓v�C�� 1 °{-,.-L-t t�.
Vehicle Claims—please complete this section check box if this secti n does not apply�
Your Vehicle: Year Make Mode]
License Plate Number Stat 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
Injurv Claims please complete this section ,�•check box if this section does not apqlv
How were you injured?
Wha[part(s) of your body were injured?
Have you sought medical trea[ment? Yes No P:ar.ning 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? s 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 szg��i�zg thzs form,you are stati�zg that all infornzation you lzave provided is true and correct to the best
of yoacr knowledge. Unsigned for»as will not be processed.
Siebntitti�zg a false claim can resiclt i�Z proseciction. Date form was completed u,/���� _`
Print the Name of the Person who Complet d t 's Form; �`��- ��"`
Signature of Person Nlaking the Claim: ��'�j
Revised February 2011
- CITATION
State of Minnesota Ramaey District Court
Ciry of --T- t � •
Citation A� . I��II��1I�1�11�1�I�II II�I Illlf�II���11 IIII I�I
620900204961 620900204961
Dl Number State
O MN D CDL
Name
First Middle Last
Address— Street,Apt#
Ciry State Zip
ST PpUL IMPOUNp LOT
DOB(mmlddlyyyy) Eyes Height Weight Sex Race Ethniciry aaro eaRr� ��� Rp
SAINT PAUL. NN. 5510'7-2450
651-266-56q2 .
Vehicle License No. Plate Year State Make Type Model Color r, Merchant 1D: 8QQg3gelqq
• (t^�-�r � 's -i ��' �� •'!' ,( L' i�� 1- F- +- t`.�•§4� Tern� ID: 0017340800�1063H019496
Date of Offense} Tirt�e of Offense ❑Acdderd/Crash
� t • � .� o� o��;�ry o Fa� o P����, � Sale
Parking Meter Number Neighbofiood Code ❑ Housing/Building Code O XXXXXXXXXXXX��
� VIS� Entrv Method; S�iaed
❑Booked �ParK/Operatg O Owner ❑Passenger ❑Driver O
Offense �ocation p �nt' s 219.�
: - - ;;r,; N 1az; f 9,69
No 1 Offense scen,��ai��,t 0 1ota1: �f=_=_-�==�9,r�
" �'� ;� ; ;, "� .. �� �:. ..< _ = / �.: � . �',? �
No 2 Offense - � s�enne�oro��a�ce � 12/18/13 17;19.54
No s ottense s�e��oro���� � Inv q; 069913 !�r Code: 015�2
�rud; Online
❑Speed 169.14(subd ): mph zone C�t��,• cor,Y
�No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) TWqp( YW!
AC Taken—AC: Test type: ❑ Refused O Breath ❑ Blood O Urine
❑Hazardous Material (DOT) ❑Unsafe Condftions �School Zone
❑Endangering Life & Property ❑Work Zone ❑Commercial Veh. DOT�
Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other
See back of citatlon 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
Driver's 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.
Please read the back of this citatlon carefully and re nd.
Officer(s)Name(s)
Otficer No(s). . CN� ; . � Citing Dept . „
How Issued O In Person ❑Mailed ffi Scene
DEFENDANT
�
Page 1 of 1
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REGISTER OF ACTIONS
Cnse.No.62-VB-14-170
State of Minnesota vs KEVIN MICHAEL ERICKSON § Case Type: Crim/Traf Non-Mand
§ Date Filed: 01/23I2014
§ Location: Ramsey Criminal/TrafficlPetty
§ Downtown
§
PARTYINFORMATION
Lead Attomeys
Defendant ERICKSON,KEVIN MICHAEL
5021 185TH LN NW DOB:04/O6It952
ANOKA,MN 55303
Jurisdiction State of Minnesota
NONE
CHARCE INFORMATION �
Charges:ERICKSON,KEVIN MICHAEL Statute Level Date
1. Snow emergency parking restrictions 161.03 Petty Misdemeanor 12/18/2013
EVENTS Bc ORDERS OF THE COURT
DISPOSIT[ONS
01I22I2014 Plea(Judicial Officer:Archer,Pete)
1.Snow emergency parking restrictions
Not guilty
06/18I2014 Disposition(Judicial Officer:Yanish,Jo Anne M.)
1.Snow emergency parking restrictions �
Dismissed —...,,.,,�� �
' �� v� � 5 ���
OTHER EVENTS AND HEARINGS �
01122/2014 Hearing (10:30 AM)(Judicial Officer Archer,Pete)
Result:Held
01123/2014 Citation E-Filed
01I23I2014 Officer Notes
DAY PLOW
01/23/2014 Summoned-Own Recognizance
O1I23/2014 Interim Condition for ERICKSON,KEVIN MICHAEL
-Summoned
01I23/2014 Notice and Order to Apnear
06I18/2014 Court Trial (1:00 PM)(Judicial Officer Yanish,Jo Anne M.)
deltrequest
Result:Held
httns:Umna.courts.state.mn.us/CaseDetail.aspx?CaseID=16166665 50 6/l 8/2014