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Flowers �� NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Mirinesota State Statute 466.OS states that "...every person...who claims damages from any municipality...sha!!cause to be presented to the - governing body of the municipality within 180 days after the a[leged 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. 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 SLVD, 310 CITY HALL, SAINT PAUL, MN 55102 � �� J ��CE�� First Name � t�d� Middle Initial ►"�'� Last Name �" t(;l�,�,��v -� Company or Business Name, if applicable MAR 2 3 2Q�2 Street Address �;�7 ►^'lG�r j�n�, �� ,,+� ��Y�L�� City j..�. �C.�� State {N1� Zip Code `j ,�/(�� Daytime Telephone !c�t S>� -3y(� � Evening Telephone �� Date of Accident/ Injury or Date Discovered Time am/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 responsible. r 2. 2 � _' �"'� ' ,�� '�'v- rh :''c' 'c��t _.!_ ti,�/�'c n �' ^ Ct ►'� ' ' �f'L.ful. � 3 ' � �t L' t�-� t� `,f,�._.l i-k� 1^Z� r l 1�/'t� n. . � �, �+V�` i 1 .� �_ � �_`�. 2 n, _ � - � F � �..] 'U .n \- - o +>. l,l t vJd,.�.�1 C� ~ � ` ..�� - . ��1 Z1" +..il�i "'�_ \��,,a --F'�.-e ):�., i..,..�.laJ�+��-�'y��tJ j � , ,- c �.,'�21``� -��C.�.� �� -�-�.-� .x r,�� j Please check the box(es) that most closely represent the reason for completing this form: � i ❑ Vehicle was damaged in an accident O Vehicle was damaged during a tow I ❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow ,f�Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property Q Other type of property damage—please specify ❑ Other type of injury—please specify ❑ Other type not listed—please specify In order to process your claim youu need to include copies 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 tiekets 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 O Photographs can be provided but will not be returned. Page 1 of 2— Please complete and return both pages of Claim Form Failure to provide a completed claim form will result in delays in processing. � � " � Notice of Claim Form, City of Saint Paul, page two All �laims-please complete this section Were there witnesses to the incident? Yes No Unknown (circle) If yes, please provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes No 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 compensation from this claim or what you would like the City to do to resolve this claim to your satisfaction. Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year ��(G Make �G�� Mode� V�r c,�-c License Plate Number `r l\i�j ;3 3 3 State �'�1 Color j�,.� Registered Owner -'j;,��q �I�a,�e.z� � Driver of Vehicle '�.�,/� �-i�;;.�LS Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniury 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 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 slating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms wil! not be processed. Submitting a fa[se claim can result in prosecution. Print the Name of the Person who Completed t is Form: 1 i,•�✓a �Ic�;,t,.2,�� Signature of Person Making the Claim�-�=" � t'J � Date form was completed ?7 " Z2-'�c� lZ-�'' Revised Apri12007 . ` � r \ : � ,\ : � a . � i . 1 __ . _. ._ . _ : : . � . � � � � � , � ; • t j i i 1 I } _ ._ � Saint Paui Police Impound Lot, 830 Barge Channei Road, Vehicle Release Form � - �, . Make:97 HONDA License#: TNJ333 CN: 12047044 Invoice#: 16003 Date/Time Released; 03/01/2012 11:10 Tow Charge: $ 123.95 Re�eased to: TOTO Storage Charge: $ 15.00 Paid by: CREDIT CARD Admin Charge: $ 80.00 _ ---� Released by: SUSAN Tax: (7.625%) $ 15.55 �� I,the undersigned,have recovered the vehicle described above. Subtotal: $ 234.50 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 f Saint Paul Police Department. I acknowledge I will report �/ damage and/or any other problems fo the Impound Lot staff Total Charges: $ 234.50 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 5�2000 �.. ST PpUL IMPOUND LOT 8?.�BARGE CHANNEL RD SAINT PAIiY.. !W. $510i-2459 651-26&-5642 flerchant ID: 80063891$4 , Term I[': 68tT34B000�063$glqqgg Sale zzzzzzzzzzzz6165 , VISp Entrv Meth�l. Saiped 1ota1; $ �3� r� � �3i01�I2 11:09;56 Inv �; �9969 Appr Cade: d99765 l�rvd: Online �ustomer�oPY � � '. rHar� vou! { i � - � � i _ ; i , ^i ;,;-,.�.,.k: � : . : � Citation# 8$$ "��r��;; ST. PAUL STATE OF MINNESOTA-RAMSEY DlSTRICT:COURT ` II)�IIII II�(�I�II IIII�I�I IIII rsi ned bein dul sworn,u on his/her oath deposes and says: I IIIIII IIIII IIII)I'II�I� I The unde g , g ,y P . * 8 8 8 7 4 2 9 0 4 * . . 'Rate of Offense� /'%"�� Tme of Offense ='�* ' ='�'"� � �. �� ,.� Year�State f�lake �� , �-� Style �"�:;:�'"'�'� Color ��', �� Veh. License No. ��- �q 3 � �� '. � � rr �� Location of Offense: � }�.�'� �� -�` �...'s .�� -�'`"� ``�: , . � . � VIOLATION: ` SNOW EMERGENCY St. Paul Ordinance 161.os FINE $53.�� (Amount includes Fnandatorystate surcharges of$13.00) � ` CN `�a�� s � - 3,,� :�_, - g Officer ,� Citing � � Officer �� Number � �� Dept. � t osted Night Plow ❑Day Plow ❑P�owed in(Windrow) �ed Before Plow ❑Drove Ofl 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 r • I P:age 1 of 1 !!IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII INCIDENTINFORMATIONREPORT 3/22/20�2 STATE OF MINNESOTA COUNTY OF RAMSEY � DISTRICT COURT INCIDENT AND CITATION INFORMATION - INCIDENT ID PAYMENT PLAN CITATION NUMBER 2321114 888742904 DEFENDANT NAME TINA MARIE FLOWERS ADDRESS 937 MARSHALL AVE S I,�, ST PAUL MN 55104 DEFENDANT INFORMATION '�ATE OF BIRTH 12/22/1970 GENDER FEMALE �+EIGHT 5 Feet 7 Inches EYE COLOR BROWN ��,fVEIGHT 135 Lbs. DRIVERS LICENSE Q957172743021 DL STATE MN RACE BLACK HISPANIC (Y/N) OFFENSE INFORMATION � DATE/TIME 02J29/2012 21:24 DIVISION RAMSEY COUNTY LOCATION NS MARSHALL BTWN COMMUNITY ST PAUL � MILTON/CHATSWORTH METER AGENCY PUBLIC WORKS OFFICER 1 814 OFFICER 2 CCN 12047044 NBRHOOD VEHICLE INFORMATION �L-ATE TNJ333 MAKE HONDA �sTATE MN MODEL ACCOR �EAR 2012 COLOR SILVER VIN 1 HGCD5534VA109968 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 � 4 �RIGINAL FEE INFORMATION AMOUNT DUE $40 FINE , 40.00 $40 FINE .00 Srchrg-2nd District 1.00 Srchrg-2nd District .00 Srchrg-Parking 2009 12.00 Srchrg-Parking 2009 .00 GRAND TOTAL 53.00 GRAND TOTAL .00 OFFICERS COMMENTS POSTED NIGHT PLOW; TAGGED BEFORE PLOW C