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NOTICE OF CLAIM FORM to the City of Saint Paul, N���I=�K
Mlnnesota 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 I80 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 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 acknowiedgement once your form is received. The process can take up to ten weel�s 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 Y L�� Middle Initial�Last Name ��t��
Company or Business Name_ N`f}
Are You an Insurance Company? Yes/�0 1f Yes,Claim Number?
Street Address 7� /�u�S�;s��'nn1 ��1,��` �L l�h .� �rrt 4�
City S-E �ati� State lUl/U Zip Code SS�I 6
Daytime Phone( /Z)�- �zv Cell Phone( (i-)�- �L�- Evening Telephone(��i ) �3- (�o iz ,
Date of Accidend Injury or Date Discovered �l"'�� � �Q�� Time ���am/� I
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€inployezs ar�involved and/or responsible for your damages._�{, Ia/a/a�„i .� j
��= ��Dm, .� wus /�f�'v�ra E�CSt �u�.;� t�h �ano(��n�, fl�t �rt -I� inf�vr>ecfi�++ o�- �akd,lr,6 i� �an,(�nP � G /�Ark�%��
J f� r / �
In-�NLLNtf�f (2/' h'1:�:�2 0. [r�irNi�t �.P#t Ti.m ��q �,nA ihfo !'lanLne He ZvGS �� G lwl.� IiAn � 1� �1S
��t Y�rn (�t.h^ .� �L �c� (�e�.s�A -H4,v r�+e c�r�r,trn ' �s uwr/_ ` (�D� Ile�l a r eueleJ� � aH�/ i.�e �
�n�� '�p� Z iM+i iSS�k,s� c �l�,�C f #er Wn�ayfBn+,1R IJtN�rv c.i "�� Sc2s�e d4��r¢r dh �2� l� .^al� re �I�o�
0. (o.N�L-c�r. �Q,�.'er (,t�rom�wrfrr �A�'oj �/la-t,�iCon in �.11�t,� �� sn 'i� or in-tlt•/YL( ilt�,ws-f.`oaf,b,� �nn� �r�na rn�a���y�,
I was h„t 2� fal�(#� an,( �� a-F / ;ssupd t�kel wRC raH�lfq1,(., J ��� ai4a�k.lf � � (s�a-
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
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow i
I�I 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 you need to include copies of all apqlicable 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 biils
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 wili not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section
Were there witnesses to the incident? „� No Unknown (circle)
Provide their names,addresses and telephone numbers: -r n,�,�U��( p,.��aoU� r�o�-
Were the police or law enforcement called? f� No Unknown (circle)
If yes,what department or agency?�n� pawl l�oC,�r .D��a�-�n��Case#or report# 1/� 6`�6�
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. �n t2r sz�-,v,., o�-
�c��(.p l, �1-v s� �}a,,,U�„e � fl�e� S
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaetion.� Vw' �.�� ;s rnu L�„e. 7G�,� rRr iz tirr (,;,�,-r�,al e�l.�ar ,�.na,r is PS-� ,�,�,�z�(
�j"fftWf � bU9D T Ll/L� /10'� QSI! -F0Y. /JlC rsiAA,1�-i�Yl / ��y.�+-�'l it.:� � /1�(Dd G�Y�U AY�n M? �7J'i�(�� Ta Y�j('/��l
O�l�f 1 Wawt ��° C,cm�en5.�hl�x �e� ✓"r -� j,K ztne CR✓ .
Vehicle Claims—nlease complete this section ❑check box if this section does not avnlv
Your Vehicle: Year � o Make �/o l,�s�-Ae v,,, Model Q 32
License Plate Number 38 4 �G I< State�_Color f3�ue
Registered Owner �n
Driver of Vehicle ue��„u �h�
Area Damaged Q,��/�-#no„t u# t,�,v LP�u�.IP� ��rh � �iun��fS i �l�/iDe.l' CCn*Ovn�!`, �t�sPenS,ev, ; Cao�a�
City Vehicle: Year Make Model
����7 ro��(e� b y License Plate Number State Color
� Driver of Vehicle(City Employee s Name)
P�G'u� �fa�rn�r�.t Area Damaged
In_iurv Claims—please complete this ser.tion C�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 �- Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone ,
Did you miss wark as a result of your injury? Yes No
When did you miss wark? (provide date(s)) '
Name of your Employer: �
Address Telephone
I�) Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this fornz,you are stating that all infornzation you have provided is true and eorrect to the best
of your knowledge. Unsigned forms will not be proeessed.
Submitting a false claim can result in prosecution. Date form was completed �, �- c�-o!Z-
Print the Name of the Person who Completed this Form: I u�y�n� c�'P�n
Signature of Person Making the Claim: `
Revised February 2011
2011 Minnesota Statutes
169.20 RIGHT-OF-WAY.
Subdivision 1. Approaching intersection. (a)When two vehicles enter an uncontrolled mtersection from
digerent highways at approxnnately the same tmie, the driver of the vehicle on the left shall yield the right-of-way to
the vehicle on the right.
(b)When two vehicles enter an intersection controlled by stop signs or by blinking red traffic signals requiring
drivers or vehicles from any direction to stop before proceedmg, the driver ofthe vehicle on the left shall yield the
right-of-way to the vehicle on the right.
(c)At an uncontrolled approach to a T-shaped intersection, the driver required to turn shall yield to the cross
traffic.
(d) The driver of any vehicle travelmg at an unlawful speed shall forfeit any right-of-way which the driver might
otherwise have hereunder.
(e) The foregoing rules are modified as hereinafter stated m this section.
Subd. 2. Left turn. The driver of a vehicle �tending to turn to the left within an mtersection or into an alley,
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private road, or driveway sha yield the right-of-way to any vehicle approaching from the opposite d'u-ection which
_ . _ __ __ __ _ _
is within the intersection or so close thereto as to constitute an immediate hazard.
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Subd. 3. Through highway; stop sign. (a) The driver of_--a v�e uc�-shall stop as required by this cl�apter at
the entrance to a through highway and shall yield the right-of-way to other vehicles which have entered the
intersection from the through highway or which are approaching so closely on the through highway as to constitute
an imcnediate l�azard, but the driver having so yielded may proceed, and the drivers of all other vehicles ,
approaclvng the intersection on the through highway shall yield the right-of-way to the vehicles so proceedmg into '
or across the through highway.
(b) The driver of a vehicle sl�all 1�7cewise stop in obedience to a stop sign, as requu-ed herein, at an intersection �
where a stop sign is erected at one or more entrances thereto although not a part of a through highway, and shall
proceed cautiously, yield'mg to vehicles not so obliged to stop which are within the intersection ar approaching so I�
closely as to constitute an irmnediate hazard, but may then proceed. '
Subd. 4. Vehicle entering roadway. The driver of a vehicle about to enter or cross a roadway from any
place other than a roadway shall yield the right-of-way to all vehicles approaching on the roadway to be entered or
crossed.
Subd. 5. Emergency vehicle; penalties. (a)Upon the inunediate approach ofan authorized emergency
vehicle equipped with at least one lighted lamp exhibitmg red light visble under normal atrriospheric conditions from
a distance of 500 feet to the front of the vehicle and, except as otherwise provided 'm paragraph(b), when the
driver is giving aud�ble signal by siren, the driver of each other vehicle shall yield the right-of-way and shall
inunediately drive to a position parallel to and as close as possble to the right-hand edge or curb ofthe highway
clear of any intersection, and shall stop and remain in this position until the authorized emergency vehicle has
passed, except when otherwise directed by a police of�icer. The driver of another vehicle on a one-way roadway
sha11 drive to the closest edge or curb and stop.
(b) The driver of an authorized emergency vehicle escorting the movement of an oversize or overweight
vehicle or load need not sound an audible signal by siren but sl�all e�ubit the light required by paragraph(a). The
driver of each other vehicle then shall yield the right-of-way, as required by paragaph(a), to the emergency vehicle
escorting the oversize or overweight vehicle or load.
DEPARTMENT OF POLICE
Thomas E.Smith,Chief of Police
CITY OF SAINT PAIJI. 367GroveStreet Telephone:651-291-1111
Christopher B.Co(eman,Mayor St.Paul,Minnesota 55101 Facsimile:651-266-571/
December 19, 2011
Mr. Yueyang Chen
740 Mississippi River Blvd
Sair�t Fau�, �,�155115 '
I
Mr. Chen, I
On October 3, 2011 you were involved in an accident with a vehicle belonging to the Saint Paul Police �
Department at the intersection of Hamline and Randolph Avenue. �
You were issued citation number 911-109-606 for inattentive driving. The Saint Paul Police
Department conducts an internal review of all accidents involving department vehicles. The internal
review has determined you were not at fauit. As a result, the citation you were issued will be cancelled.
I understand you have a tentative court date scheduled for February 15, 2012 to contest the citation. I �
am notifying Ramsey County District Court of the cancellation. A report has been written to document ,
this under case number 11-264-156.
I apologize for any inconvenience this citation may have caused you. Should you have any questions, 'i
please contact me at 651-266-5999.
Sincerely,
\��.�.� �?���=-
David Mathison, SENIOR COMMANDER
AA-ADA-EEO Employer
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