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Sims �iECEI�'�C� M�R � � �o�z � NOTICE OF CLAIM FORM to th���,t����aint Paul, Minnesota 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 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or ofher 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 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 c�On-� �. Middle Initial Last Name �j��s Company or Business Name Are You an Insurance Company? Yes/No If Yes, Claim Number? Street Address ,� .�-/t� City State ' Zip Code � Daytime Phone ( ) - Cell Phone (�)�-�vening Telephone( ) Date of Accident/Injury or Date Discovered����J Time �S .'y��� 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 damages. d,t/-01-o`�j'/�=- ; o fa � :�. . � rZ ,,�-L . ✓ o n. . e ` � F /' � C t�- 7--r/ st.�t�t .y, ��o... ('ar►1 `1 �w�LL�rLr r d �n �i..r a � S'6>�� A� �'��.�isa i`a�- IJ t L�i� � C ,,� � V t /' � • , C Pleas�heck 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 'y�My sTehicle 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 youu need to include conies 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 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 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? Yes No Unlrnown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes N Unknown (circle) If yes,what departrnent or agency? ase#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 City to do to resolve this claim to your satisfaction. ,S Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year /�'� Make Model O� �C- License Plate Number /� 9 f/ tG> _ State�Color /'e O�- � Registered Owner .SOn i�, S'iM.� Driver of Vehicle ,� �/���� �i"�►s . Area Damaged City Vehicle: Year Make Model License Plate Number State � Color D�i,ver of Vehicle(City Employee's Name) Area Damaged In,�urY Claims please complete this section ❑ check 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 o 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 N 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 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 J'��'��-- Print the Name of the Person who Completed this Form: a.i� � �J�,�ih <' Signature of Person Making the Claim: � .,���,-.� Revised February 2011 _ T.� � � � � _ � ��s� G�a� � � � /`-���-��..�s �— `" �2 f�t/1 G�J/'an y�y// �d�.tJe�. __ / � � rR��� � �� � d�;�� ��� -�.� - ,� � � ,.. .�� � _ � � _ � � � �. � � � � .� `- � � Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: FORD License#: 119HWV CN: 12047044 Invoice#: 17101 Date/Time Released: 03/01/2012 19:28 Tow Charge: $ 123.95 Released to:TOTO Storage Charge: $ 0.00 Paid by: CASH Admin Charge: $ 80.00 Released by: MELISSA 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 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 i . Citation# $$$ 74v 735 , ST. PAUL STATE OF MINNESOTA-RAMSEY DISTRICT COURT I I��I'��II�II�IIIII��I IIII II'I f The undersigned,being duly sworn,upon his/her oath deposes and says: .,,.' f � � ,,.. :�r-- * 888743735 * � Date of Offense �. � � / ' ° �" Time of Offense ' - ' ji�•�' ���� " Plate�'".� ��I '� �� 1� .� � '� . - Veh. License No. ( � �+' R` Year � State� { __P.1ake !��j !� Stylc� `��3 f�lr Color � 14 .� �'` !,;� � �� ; � �,"� Location of Offense: �- � � ' � � �� i �� � �'�� � ` VIOLATION: �� SNUW EMERGENCY St. Paul Ordinance 161.03 FINE $53.�0 /� r� � � (Amount indudes mandatory state surcharges of$13.00) C N J <'.�.' I�` �� `7 ��I �/� Citin � �r Officer �a'-'J� Citing 7 , � �;�, Officer '�„" - Jr"F.�.__.,, Number "` ..' r Dept. � • r.` , ❑Posted Night Plow Day Plow Plowed in (Windrow) ❑Tagged Before Plow ❑Drove Off OFFICER'S NOTES ❑NO PLATE VIN: Citation can be paid at the Impound Lot. Please read the back of the citation for payment instructions. CITATION . To pay your citation online: 2ndavebpay courts.state.mn.us , . For additiona�informatian or to pay your fine by telephone using a credit card,call: 651•266-9202 � Please have your citation number and credit card available. • Mail payments to: Ramsey District Court Make Checks payable to: Ramsey District Court Traffic Violations Bureau (A charge of up to$30.00 will be assessed on all returned checks) 15 West Kellogg Boulevard-Room 130 St. Paul, MN 55102-1613 �------------------------------------------------------------------------------------------------------------------------------------- Violations Bureau Locations St.Paul Court Suburban Court Law Enforcement Center 15 W. Kellogg Blvd., Rm 130 2050 White Bear Avenue 425 Grove Street St. Paul,MN 55102 Maplewood, MN 55109 St.Paul, MN 55101 Office Hours:8:00 AM-4:30 PM Monday-Friday(Excluding Holidays) Hearing Officers-By appointment only. Call(651-266-9202) -----------------------------—------—----------------------------------------------------------------------------------------------• Payment and Penaities If you wish to plead guilty and submit payment for the offense on the reverse side of the citation,you must do so within 21 days from the date the citation is filed with the Court. It is your responsibility to present your payment in a timely manner.Please allow 5 business days for processing.A$5.00 late fee is added to all unpaid fine balances.After 40 days from the date the citation is filed with the Court,an additional delinquent fee may be added to all unpaid fine amounts and the case may be referred to a collections agency.If the offense is a petty misdemeanor,failure to appear will be considered a plea of guilty and waiver of the right to trial unless the failure to appear is due to circumstances beyond the person's control(M.S.169.91)and(M.S.609.491). �------------------------------------------------------------------------------------------------------------------------------------- Appeal To plead not guilty,or to plead guilty and offer an explanation,take the foilowing steps: 1)After 10 business days,call 651-266-9202 to confirm that the citation has been filed with the Court,and 2) request a hearing officer appointment.You must have a photo ID with you when meeting with a Hearing Officer. �------------------------------------------------------------------------------------------------------------------------------------� I understand that by�ayina this fine I am entering a plea of g�iltv to this offense and voluntarily waive the following rights to: 1. The right to a trial by the Court in which I am presumed innocent until proven guilty beyond a reasonable doubt. -__ _ 2. The right to confront and cross-examine all witnesses against me. 3. The right to remain silent or to testify on my ov�behalf. 4. The right to subpoena and present witnesses to testify on my 6ehalf.- - -------- _ I also understand that this offense is a petty misdemeanor and the maximum penalty is a$300.00 fine.