Loading...
Cushard, Kimberly R������� SEP 2 2 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota CITY CL��K M�nnesota 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 days after the alleged loss or injury is discovered a notice stating the time,place,and 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. If more space is needed,attach additionai 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 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name�i�1�1��(�'��( P Middle Initial�,;�Last Name�� .1� ��l��'�� Company or Business Name Are You an Insurance Company? Yes�.�io� If Yes, Claim Number? Street Address 2�)U'( �1�15 e� �`I V e � City�� f�G��1� State �'�I I� Zip Code J I �� Daytime Phone (�j�) �'- ��L Cell Phone( 6 I )587-4% T�"I Evening Telephone( ) - Date of Accident/Injury or ate Discovered i - 'rJ -�+�f''-� Time � �J am/prr� _� Please state,in detail, what occurred(happened),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 your dama es. v i"� Ir {(11'1rS�1!'t U �' "(�-' � l�r 'vC15 � ( � � i� `j '^ '� �--� �_ � • . �� � F c � F j � Y i f (� � i � , u �S � l � �r � � � 'V i � � �5 �1'• + � (� '� �i _ /� '1 ` c� �{ ; �, � � . J'�J �'� �f ,� • , � \,,;, � � 7 (� r " Please check the box(es)that most closely represent the reason for completing this form: �J(����v� ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow���y���'� ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow �C f"('tl�S � My 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 v�:: npPd 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 propeRy 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 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 j�ht �Y1ChCl 1'1��I�io'M � Srl�1�- 1—hP �I�v�r� �-9 � 5� 1�ftil �;�Ii�� t ������;, � . t�u�e� ��� ���n� �r�� -�o �►� �i��ZS r', t� `���- fit��<t -���t C�'►�I K i�i�'�� �r�r� �N� ���� C I ���Y 1 �n ��I�� t'�Y �c�l �,t:��1 t�,� o v��� �i �Y'�0 � '�� ��`�4'�S 1^v^��'✓d.C� �� (11 �1SC, 5Y'�� �tti' �1s -�'�'►�Y� 1����� �1�is �''i�� ��l�P.�� f�( rc�st- r��cr, �ti�-t- t� re� t� v�Y,F�� -t�►�s c�s sI�� ��v�� � I ���i �� ���, . n t�� ���w�� i s �1 � ci�f i� � ►ra rv�p� 1� _ 1 '��Ylt � �Y� '�, v� ,- - ��(n� �`�� ��'��I ��^r�'1l�� C��7J � �l � � P o r� 5��1� �c l� � .� �� �t��� r�►o ;�s��,�s � �- �f����,�����. �� K ������ �� r�� ����-, ���e� -����'�� ir r � � f� � 1�a'�{�'1 I ��l 4��E�i S r�1�'C�, � �J��► L I o t�l Gt�,^ c ���'�f 4� I ������l� ����'S i��C- I'l� �1 � �`►���r► a��� ( � l�f iy� �'�r�J i1S�., , "�h C. ��'11' 1(\r��S 0�{' . •A�'✓ �l."!� �1 i'1 C': f'�'1� ( 4'������ � , � � /� � J . � �b i ��t,iJ �'L�1� � { � fnr t+S t�jf�+� u � . - — il��� ����t:�� i���i��� fc������I������' ��� � (`t� �� C���v��.� �����K, nUt C��,YI V''��^ trit' ��I''�r� a� V'� �'�1'('V,t �� JVI�i {���IL �"'�'1 J� P� ►�-- ��/{�" ��� lc��✓ti� b�;CI� 5 c�c����S i�-�r� s' r 'J���n��� I�� �PL _.. � ���- ^�,�� ►��!�1 ������-e�������-�-- �� ���Y�L � ���n �r , ����- ��- -�-� ���.� �`l�l�1�" ���I� �LC� i'l'�J 1��(� t�C. C�V' �11ri ���ip{� +J� —�—�/'i L ��►�`�� K• . ��r ., P 1 �-f-��c� � ���i� t �c�v�, ��n L� � Y���r�l 5 fi�o ��c�ti��- �i- -t��1,���, c+s � l� i� �^�� ��'�t 1�`�l��s �s Ke.G� �� �,/'zC'- I�� -�'V'� bS l, ���YY:�� 1r� N�l�(�1'� Y�f�S 1�rr�� ��'- tr,�, ���r) ��fh�►�� �+ is Ct���� -��',�. �f�� ��t�►r � �`� nJ+� � � ��'`> �a�� l�� f�I 10 �� i'ru ��p ��'��i►� -}-�� �{��''� ►�s fo ���r��t=t� t1'� i� �i c�d ���� �r�'�� � � � �� � �� ��: ������- fi����-� �������� ��v�� �� ��s �r� -t�l�r ��c t r � ��t� c � K '�.� t��Pli��ve� �� tr� e�ic�� ��1� C�a��,�.- ��i� �v� � o�v�c-�l�1� i �NJi�ll���� ��1G�1�� �'�i l� C�"l r i ��!'i �� �1 r���'z� . - -- J Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease complete this section Were there witnesses to the incident? es No Unknown (circle) Provide their ames, addresses and telephone numbers: Y i�(1 9 1 f. '� ! "1 J i ('G�1((C'� C11'Y� �t'�� n 0 �'!'it' � �J t L�1S it " � �' 1'� C r/1 tV ���ec ��1�1'�i�tic ('��c��,1p� o v5�-i3f-��z Were the police or law enforcemeht called? Yes 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 park or facility, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. Please indicate the amount you are seeking in compensation or what you would like the ity to do to resolve this claim to your satisfaction ^�. � �i� I dV�' G 6 �1 �� ^ . S �d Pi «'S t t an�l ► Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Yoar Vehicle: Year�_Make OC� Model A�'1G� � License Plate Number f{� q 2- State�+�Color Y�(1�'1 r�"[., Registered Owner � v�s ht^r Driver of Vehicle � — 49S Area Damaged�[/��.} City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniury Claims please com�lete this section �check box if this section does not apvlv 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 i 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�_� Q � Y��� � Q���P By signing this form,you are stating that all infornzation you have provided is true and correet to the best of your knowledge. Unsigned forms will not be proeessed. Submitting a false claim can result in prosecution. Date form was completed �- i�- Z��`f Print the Name of the Person who Completed�is Form: 1 V�1 ��Y �� ���� Signature of Person Making the Claim: � � Revised February 201 1 Saint Paul Police Impound Lot, �hicle F�elease Form Make: 96 DODGE Licer sr rwu��i`p'a�An�oT Invoice#: 152641 ��ctw�� SAINT PAUL� �N. 55187-2450 Date/Time Released: 09/1Q/20i4 19:C 651-266-�2 irge: $ 60.00 Mercha�t ID: 8006380144 Tero ID: �17340000809b3�14408 Released to: TOTO Sale �harge: $ O.OQ Paid by� CREDIT CARD �aXXZ)cXXXZXZ�� �arge: $ 80.00 WI�p Entry Method, S�iped Released by: LARRY Total; $ 154,68 25%) $ 10.68 I.the undersigned,have recovered the� (��/la 18�59�� $ 150.68 i will check the vehicle for damage or a j�y q; � �PI'�e� ��� may have occurred while this vehicle w �; Q�]l� harge: $ 0.00 Saint Paul Police Department. I ackna damage and/or any other problems to t Custoaer CoPY rges: $ 150.68 on this form prior to leaving the impoun T�y�� Damage and/or other problem: y Police Report made: Yes_No_IF Yes, CN � , If NO, Why? TO PROTECT YOUR RIGHTS REPORT ANY PF�OBLEMS/DAMAGE BEFORE LEAVING THE LOT I Signature ��2000 ---_____-�__ ---------,--.__...�______:.��...r._..,.�.....�.,....,.._ i ,..,,o,.,.. _ ..._.__. a------ -- ti� � ���T R�1�- _ �tl�p!i Mhn+�ss��°t°: ,_. _. . : � �, �,. .. . ,.< �t . - -�- , {,F,� , ��{-- �° .,� �.[/1�� ��`° - �'' � '`�:� �" rr�..�� , �� - '�.. � __, r � �i�� � � � � � � � � �* � ;< � ��� = Amotxrt indudes F� �� .� .�,z� , � �"'�'� .: �+,m_. r�,����,: ��F i� Mir�esota SYatute 35 027 1�. ,mrbd.8 a�ld' `, �`� � ._:. : , _ • t;, �e�lshg.suidm�9s: 573.00 TtalNc 3wdlmge"�78:itt1' 11�I�11►�Irt =-:_.. .�:�' . . .... S 3H.00 Ir� DOD('.E Yooa CAitAWN Cdor.YYMT'E � '.�..... ................... ......................................... ', "_� 38.00 Typr PASSVEH � �-St P2u1...._..... . ... . ._: .. 41.00 .: Zop�t .9i.Paul .... .... ... . '�bMo�nh. TabY�a�. ��,.- . _-..4�.�� .... ..y...».. .. .. ,.:. 38.00 , 41.Q0,, )at�of01►ens� 09HOf2014 Time oltM�nse Ot:SO `�-4s. -� . . St�k4EHOfd OINflp " . - ���- --- - .—. ° �o�qc r�hon ami sUeetlalley,at the same I• df�;i�ri�are tlw�48 eor+secutive hours• } � � ; . ,.., _, e,r � ��a� "�� �`< 9&11D _� _,�: _ ., - � 56.00 �.a:�� .,_a,���».:.... � ... .., _ ..�.. .. �, ;,�,. ...._.... . ��-� - . FaFcon HefgMa .... ..............._...................._....... 51.00 , .,�, t�Pa4� i �w�acation NCA9EAY lnterstdriySLreet YO'��i 9trsR =>.-g.,. . i��/ '~�: l��i � �, `°��. i�rl�aerr Perma Zone Siyns Yis_ � � ' �-� �-����.� . Il�tr CnaY�0ut Pr��d. {►w.1w) Time zone ��pp�n'�3f!CotM�lOt19e �� 15 West Kellogg Boulevard �' �R�9� � St Paul.MN 55102 _ � io.r�sr ii4�t ;.,. ::�.; '`�'" ��"'�: �ri . s_ � . . . ..... . �,� -���� �,�� dri�r 4�► : . • �-�a st.�a�t,:�' � pe�dt deieclre meKrs py rwon Mx�ezt business day `; `'" Ca��651►266-9776 �r To pay your fine by credit card,wait 5 business days and then cali ,¢ (851)286-9202 � , � � � h t,. t�d�:o�P�;�oUfYlnsu��`o:Nn Driv�ra..e.ense tn Poltession,Praof Of Yz3urant�andle� �I p Jlll . .. I . .:�(�aY... r�ra Lic�na�ehould be a��own n au oi t4.�Ywiia�s Bvw�Loe�ns ia�W Owe�ih�+ �� I II �� .�-� � �tf11B�'�fl�y • - I� %IMI�Me6I0 M+�PP� ,:�lease ca6 659-266-9202 to schedule an appointmeM [;Mrl+��s�si�r ar2W�rar�![lYiEaYtys� ', uf °z'� �.,jytal�uss�+arr.r:.ris s���ir�+�^G•a.re sriE C.�r i�ri� � � _ �a�,�..s..�+..�E ra.s ar a.r�rr F To find out iF your citatan is payable witkwut a cou�E. ���!' � k f . - , �:,:. - f- - �-,;' .late penalties�or how to see a hea�ing oifioer i I � sw sa►.•� °- " - i...rti.a+s c.r� � wait 5 days and then go to: , 'a�.�c�Nr�.o.�sro '� �°� �s�-�s��-� 2ndweb .cou � � _ Y►sr WS6+.,s"c.,o-; , ,� ,,� � � ' � ":�+,� �z�rcis.-=r�:�!o RamscyD�s!rCo�.it `�-- .,�.. .:.. ', __ . ,. .,.;. � _ � � ^�..;:� � .•'� z yA�dup te f3D 00 rv���b�oseas�d on slt nwmeo c3+r_ya; ..-�. . _... _ - -- -�-- °---- _—..._ . ._.. . . _. __ ,. �� � V�olat�ons Su»au Loc�tlons y�p�7�� Suburb�n Court Lew Enforcammt Cerrter 3 w h�g��y 1�p 2060 4Vhk�Bea Avs. 12d Grov�Strnt y� Py�y.��t02 M�pNwood,MN 66108 St.Psul.MN 6610t �fic.>i,_, e.J.-��1 4:90P M. Mon�vv-Fndayj�x�h�uinyHoliday�) HearinpOfieere .�/r: �a�Mn�nf.�.����_d1��b.�,�u3eN2� � . .....� .,� . . �... ,� . .. _ . _ -_ ' - __._ __ � . .� c--,�_iQ��..tq_ , Payment and Panaltlss you wish to plead yuilty for th�oRsn��(s�on tM rw�rt�sid�of th�til�tion,you mud do w i ithin 30 daye from ths dale ths cltalion ia Rl�d wRh the CouR.k is your r�sponalbilNy te ressnt your paymmt n a tlmrly manner.Plusa dlow 5 busin�ts dayt for proua�Y+4 A i[p ' te fsa Is�ddad to a�i unpaid fine bdances AR�r�0 days Gom lh�date ttr�r1��M� �. is Court addkional delinquent ttes m�y be�dd�d to ru4�db a� I �.�.,.-�Pr1ltw��mqrirKLd�:t)n/wrrrlr0�!/��lli'��itliiyl�r�f!*�r'� ���arts!�rati�rt���{�a6rrr��a4car�peR'p` '�raiisia�i�I�ii���wir�m��_.'.�crs - -- osa J�.c+.+.'^� �.. �r�r b thr�r+t!o t��.w�a`hr�.i�e �!7 s�'o r*cuaYan.-r a beYwM C�r �w+�csrc-a�.r s +ei at a _ _ �PP� --- � - -- - -- --- - - o p�ead not yuJty.or to pirau pu�rt;a*+a a!'er an ea{Nan�wn 1)ARer 6 business days.w!:o�1-ib6-5�l0 COnR�m Ihit tht U[ati0n h�3 Otl�R�td . with Ih�tourt. 2)If th�cibtbn hu b�en M�d,nQuest a lirerinp oTur appcintment. 3)When you urlva at tM�Vfolaticme 9ureau,fetl the cashier fhat you have a hearin� oRlc�r appoinlmari.You mu�t Hw�a photol0 with you. ___ - -- .__ .. __ ------- - __ _-- — �ntl�rstand thrt by PAnNG THIS FINE�AFt ENTERIhG A PLEA OF GUILTY to tha of►�ns�ls) id voluntanly waive thE follow�ny ripht to: ����� �� �llikki ���t��� � F'r�i, �ep �y � : �9 P� � 4 : �9 P'N1 � � � _ � .� � + � � +ir� � +r' 4 : �9 PM � ` � �! � � n' �f �r Th�t me�ns a � � � . 00 �n� n�i ht�ors �om I�in�d � � Ye�h I w�uld 'ust ma�e 1