Courneya N�3TICE OF CLAIM FORM to the City of Saint Paul, Minnesota
` Minnesota State Statute 466.OS states that "...every person...who claims damages from any municipality...shal!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 additional sheets. Please note that you may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
_ requested. �'his form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOC[TMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL, MN 55102
First Name � Middle Initial C� Last Name L�rne yc� �+E�'���'��
� �
Company or Business Name, if applicable MAR 0� 2012
Street Address �l� ,Q���r S'-f ��� ��� ��.���'(
City ��; �� , State_�'�,.� Zip Code -SS/f
Daytime Telephone �2 �GG- O�c�l� Evening Telephone �) S'�y,,r,
Date of Accident/ Injury or Date Discovered �G��/Z Time � ;G/ �/pm (circle)
,
Please state, in detail, what occurred, 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 respon ible.
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MAR 0��Oi2
Please check the box(es) that most closely represent the reason for completing this form:
��TY �.L��K
❑ Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole ar condition of the street ❑ Vehicle was damaged by a plow
/�Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property
Q Other type of property damage—please specify
O Other type of injury—please specify
❑ Other type not listed—please specify
In order to process your claim you need to include couies of all applicable documents. This is a general
guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
O`Towing claims: legible copies of any tickets issued and copies of the impound lot receipts '
O Other property damage: repair estimates, detailed list of damaged items
O Injury claims: medical bills, receipts i
O Photographs can be provided but will not be returned. I
Page 1 of 2 — Please complete and return both pages of Claim Form I
Failure to provide a completed claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul, page two
All Claims—please complete this section �
W�re there witnesses to the incident? Yes No Unkn�wn (circle)
If yes, please provide their names, addresses and telephone numbers;;'
Were the police or law enforcement called? Yes ,� 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 helpful, attach a diagram.
Please indicate the amount you are seeking in c pensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction.�2/�'f'�
;
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year /9q1� Make {�v�, Model /,SQ
License Plate Number ' /' State�Color ���.y
Registered Owner �,,,r�,� �
Driver of Vehicle � ` ''
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injury Claims — please complete this section �heck box if this section does not apply
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 additional pages
By signing this form,you are stating that a[l information you have provided is true and correct to the best of your knowledge. Unsigned
forms wil! not be processed Submiuing a fa[se claim can result in prosecution.
Print the Name of the Person who Completed this Form:
' Signature of Person Making the Claim: 'L�
Date form was completed� -�i'41�2 Rev�sed APri12oo�
�
I��� i Page 1 of 1
���JIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII INCIDENTINFORMATION REPORT 3/9/20,2
_ STATE OF MINNESOTA
COUNTY OF RAMSEY
, DISTRICT COURT
INCIDENT AND CITATION INFORMATION
INCIDENT ID PAYMENT PLAN CITATION NUMBER
2319879 888744913 �
DEFENDANT NAME NORMAN GEORGE COURNEY
ADDRESS 115 ACKER ST E
I��� ST PAUL MN 55117
DEFENDANT INFORMATION
DATE OF BIRTH 6/14/1977 GENDER
HEIGHT EYE COLOR
WEIGHT DRIVERS LICENSE W193280599413 DL STATE MN
RACE HISPANIC (Y/N)
OFFENSE INFORMATION
DATE/TIME 03/01/2012 04:01 DIVISION RAMSEY COUNTY
LOCATION IN FRONT OF 115 ACKER COMMUNITY ST PAUL
METER AGENCY PUBLIC WORKS
OFFIGER 1 999 ,
OFFfCER 2 CCN 12047044
NBRHOOD
VEHICLE INFORMATION
PLATE 787ARB MAKE FORD
STATE MN MODEL F150
_.. _ : _
YEAR 2012 COLOR SILVER
VIN 1 FTEF14Y7RNB74870
RESPONSIBLE PARTY ID METHOD
NONE
OTHER SYSTEM IDENTIFIERS
CN NUMBER
CHARGE INFORMATION STATUTE/
STATUS REASON JURISDICTION ORDINANCE DESCRIPTION
CLOSE FNSUS STPAUL 161.03 Snow emergency parking restrictions
, --�.
ORIGINAL FEE INFORMATION AMOUNT DUE
$40 FINE 40.00 $40 FINE .QO
Srchrg-2nd District 1.00 Srchrg-2nd Disfrict .00
Srchrg-Parking 2009 12.00 Srchrg-Parking 2009 .00
GRAND TOTAL 53.00 GRAND TOTAL .00
OFFICERS COMMENTS
PLOWED IN (WINDROW)
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 94 FORD License#: 787ARB CN: 12047044 Invoice#: 16747 '
Date/Time Released: 03/01/2012 18:22 Tow Charge: $ 123.95 �
Released to:TOTO Storage Charge: $ 0.00
. Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: ELIZABETH 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 vehicfe 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
Signature l�Vi zc. si2000
� � � . , . : � � . s:+�. . . . . ._.. x�-
�Citation# p '
, ST. PAUL ��O �����;� v
STATE OF'MINNESOTA-RAMSEY DISTRICT COURT ` IIIII��II�III�IIII�I��II�I�II I
� IIINII111111111IIIIIIlII.. �::_
' The undersigned,being duly sworn,upon his/her oath deposes and says:
: , , *:$ ;8 .8 :� .,4:4 g � �3 *;
i
' Date of Offense y'� � � � �� Tme_of Offense Y� -� �� f �`� .
; .
' � 1 . � Plate , • � � �r
' F $ ��
� ..�., ���,� a � $
Ve.h<License No. � ° :� Year =�:�� State �''`"`� �`�- Make ��°�� °"`" Style � ��`��'•� Color �` � �-
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� Location of Offense. '�`$ �'��"--' "-^�� ��'�5" � � '� �'•�� "�� .'
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� VIOtATION: m�� SNOW EMERGENCY St. Pau� Ordinance ts�.o3 FINE".$53 OO_`
i (Amount includes mandatory state surcharg�s of$13:Q�)•y
CN .e� }; � -
iY' f�'N�. .�'M �a�'-�b'.`�'F S� . . .
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Citin9 �"��i..� � �.� � �,.., Officer �� �-�. ;F�.;. Citing :.� � ; s
Officer `�� - Number �° �� ; Dept. �'� ' � � �'
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❑Posted Night Plow ❑Day Plow 4a1�'iowed in(INindrow) ❑Tagged Before Plow . ❑Drove�0ife
OFFICER'S NOTES
( ��
� ❑NO PLATE VIN:
` Citation can be paid at the Impound Lot.Please r�ad,the back of the citation for payment instructions, �.;: ��
CITATIbN ��n ' - .
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ST PAIA. It�UND LOT �
836 BARGE t�iAtWEL RD
SAIN7 P�1UL� 11N. 55107-245� j �
�� 652-266-5642 �
1lerchant ID: 8006380144 i
` Tarm ID: (�877340Ff0080436s8014405
� • Sale I
:zz�zzzzzzzz5484
VISA EntrY Method.S�iPed .
Total; : 8 219�50 ;
93�01i12 . 1�;21;36 '� .
Inu #: 09�9 � p�pr Ca�e; fl212�R i
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