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Harris, Jamal . �.-�_ d[i�esaora Siute Srarrie 46C�.(i5 states tJr�"._.every'fiesson-..w6o cl�es�+Ses fin�n a�'s�uy-- � ,�!�to twE 8��8�3'af��l�'w�lun 180 daqs afler Abe�ad lncss ar i�rsp is�s�er�a woAUa�����fowG�.aid Cfli"M1�7CS���K t�Nl[A�C�O�Af Of�IC�IC�Alf�» .} � �. �,,�9 �1Ah � �������y������,e�����.. rc��so�� ���'��,Mp�i, �eds. Ple�se�ete mt�...ay u..9..c�e o..tacMei bry�¢�.�ar c� �Q���as sa�i�ers��as seoe�rary is aqii�yesr dais,�d We �f`�o�as be'i� reqs�. 'I'iis tie��eost be si�e.d,a�d brf�pe�es ea�ie�i. It s�ies�oE sPliy,�►rife`N!�►'- �„: + �� ',-'i, °_` ` SElWD�OM�i.ETT�FORAI AN�()TH��t Dl�.`'�11�f�1V�'S fit�. C'ITY C'LEAB,15 WFST BEId.OGG�LVD,31a t,'iTY HAI.I-.SAINT PAUL,M�t 551�2 First l�iame s„�� �; �P, � 1�+C�ddie hritial L�t l�Tame ,�A k 2► S _ Com�uY or Busimess N�ue,ii'��izabl� Street A�e.ss C� � L-t-i 1� �-t - City ..�-t �t�-rl u� State 1� l�� Tp Code �� 1 c7� I�m�Te�cpho�o�e 5( ti1-i } Z I.�j � �l C��2 Eveamg Te1�ep�vae .5C(_''� 2 IJ� ��-1 c��Z. Date of Accident/injury vr Date Discovered Z- �.�1 '1 Z Time 3�•�� mm/p�n(��e) P�state,ia d�ii,what occorn�d,afld why you ffi+e submimng a ciaim. P�e indi�Le why os lww}� fee�the City of Saint Pa�l cu its employees are urvolved andlor resp�nsible. �.�.+nJ L �� IL. � ('�C_.Cif tili� A '�'�CYif f �-F,uS� 'f i')E C��J Q� ��f ���L'� G�Hi/�'l � vJHS !� JNC.'...i , '� t„� C��h�,�� tl�f pl�w� cHr�e T n�ov�il mv cAw�snn���-IEc1 �,�,����,�� r��i rio � ; , -�rtL' �i�'ti C� ��+�2 ' ? �A��' �. �IV Yli.•a�C. �!-l'�"C� '�'hE �'�LKE'� MIAN �rl��lt_nt.l� h'��'�G�t� i:�� "�'��C ya� I cx�►Ai,� r�'r��m Z �:,r�SN t iJfll'k +1�£;�t -uh£N +hE-�io:;:,:� CF�m`� ,Slln`"f.�� h��-- — �,;«� �� -4t�t �chc� � 1�,��° �r� t11��St��Zt� Hc �n cZ ht k��� ��c:�tiy -thp.-t h �c�.,ldr.�=4 -}AK�- -�1�t ��cK�t bv+i k b.:� ht �,:;ca��\ JGu'1� -i'h�1�' Y1t i�Jrl.7 '.��GzJ< �7PfV� r.�c h��� ^�'�� _tx�'��110�{, i �,��kt un i 4i' ilPu'�, hfc N �"u �f[� t''a�L'� �1�t �J�� ��_ c~f�! ,�1�/ �AI'� �_r-,` ?,} r.. . �' Z_ i[ � � �C C�1CC}'.L�IC t1Q7C(CS�L�1�IIIOSL CZOSCht IE'�RCSCQL�1C����OZII��4FIIg�115 fOtiTl: L7 tiehicie was ciama�ecl in an ac;ciuenl �Vehicie was ciamageci c�urin�a tc�w �,,�,/Yehicle was dama�ed by a Po�o}�nr c,on�itian af t�e sLreet ❑Vehicle was damaged by a plow i�Vehicie was wron�fullv tcfwec�an�czr t�€;kc.tEkci ❑Iniured on�itv urc�ertv t'�. otfier type of property ciama�e—P�e�Y - - - a f)tiier tvne of iniurv—piea.te s�c:cifv t'�Other type not�isted—g4ease specify In or�er w orocess vour clai�t�ra���r�ies�f�il�i�e d���ts. 'I�is is a ge�l �deliae of wfiat shonld be su�nit�ed with a ciaim form,b�it is not aii iaclusive. Yau may be as�rsci w �xtinride additioaal i�fotmatic�st ciepeaciing on ya�►r claim. i�Pre�erty damage c�aims tc�a vehieTe: a�Ie�st twe�esci�tat�s fe>r the reu�airs to yc�ur vehic;Ie,t�r t� accuat bills and/or receipts tor ttt�re� O T'owing claims: IeQiuie conies c�f a�v ticke�s is•.scu�i a�i cc�pies of the imtx�und Iot rec;eipts (,3 pt�er property damage;rep�r est�mates,detailed list af damag�ed items O Iniurv claims: meciicat bilL4.roeei�rts O P�Otographs can be provicEee�bs��ril!�t be r�t�rrte�t. i'a�e 1 d'2—Piease uo�piete gad�re��es a[ �t;l�Fars� F�t+�Qnwide a t�id,ed da�f�w�c�aelt��ie�+ooc�. ♦- •� � � '� � , ' � . 1 .,. . ._.�r Wat�e et Cf�is Fe�s,Cit�r of S■i�t l�i,P�t�►'e All Cl�ms—dease cagois�e t�s� Were tbere wimesses to ttre incident? Yes � Uairnown (circle) if yes,P�Se Prnvide th�r aames,ad�ess�aod�i0ne�nber�: Wene the pofioc ar law eafo�oan�t ca�kd? Yes v U�owa (circk) �y������ Case#vr rego�t# Wt�exae did the acx:ident or injury take pla�ce? Pirovide sti+eet add�s,cxo�s str+cet,inte�section,name af park or facility,c#asest l�clmse�c,�. �ease be as dctailed as poss�e. ff hetpfnt,a�tac�a diag�n. Pkase indicat,e ti�e amou�z yat are sericiag in axi�eas�iccx�5+nm t�is ciaim ar wl�y�oa would like the City to cio to neso�ve dris claim ro yvar s�ction. i:.�. i �,� h�a,z 5� +-h�: :�G� .5 L' Ve�ide C� olefse co�te this scctio�a 0�check boa if this sectian does not au�ulv Yoau Vehicte: Yesr Niake Model License Pl�,c Number St�e Co�oc Registered Ownet I)riv�er af Vehicle Area I� City Ve,hicle: Year Make Mode� Lic�se P�a�Nmnber St�e Colac Driver of Vehick f,�►�'s Na�ne} Atea D�od IHiarv t,'ta�s Dlea�e co�k�e t�seetion Ll check box i�this sectio�does not avptv Naw were�injvred7 What part(s)of y�x�r body wer+e injured? Have yuu songht medicat tr�ment? Yes No Planning to Seek Treatment (circle) When did ynu receive�t? tPro�datas)) Nanfe of Medical Pmvic�er(sj: q�s Teleplwoe Did yon miss wark as a resntt o�yoor ia�es�T Y�s No Wl�did you miss work? (pmvide date(s)) Nau�e o#'y�r EmPioYer� Add�s Telepho�e 6�C�cek be:e��o�a ue att�c�mare p�ges ts t�da�tor�. Na�cr e�sd�i�ie��[s�- ��a�I�•�,����j���r.,:�.d.srar��+..�esa,l�ei�e,rd��e� U� �r�ea wi8 wet it� S���t�for aa naadt ie p�sae��irw. ,,.� Pr�t tbe Ns�e af tbe Per�wLo Ca�le�e�t�is For�: )A m ta 1 4�A�2 e �.S S�,aature�P+ersoa Mai�tie� ,� '` r , '-;� Da�e for�.►a�oo�a�ie�ed '�'i'Co �1 Z �;�a,�u 2�m � — � �-- -- ----- —�--L _���,�►d g�,t-- �\1a-� th� +�cK��_J��c�_ bE���v c��5,��ss�)_. � � -I�h�.--- ------ �,c���fl� bF�;�v c�,�S������.L���n,_�u%�� �±��_S�1�� ' a�� ���----- .l� � �UU1dN �� �llA�f. Qb�"�tN � ��GK�{ M �/ Cfl2 �vou1G►v'-�' j-lA�` � - � _ ��?__ ��s�.3:��_ Sc> � 'm S�c: K+�►� kl-,E 21�i . J�__1�.�,pA�cl �c� �r_\��, �' r _ ' • ' ' - � - ,..�'�l i �J� _,P�.u� ps�\1 C.� �:cv��_�_�r�Ca I C;'� :�_��1�5:��.�� A C;A 1/-��-`�ac'� !�` -------- j , . . �ot� tal� �-�1�5. �iN�N%Iv'�cN�E��c`��i�r�1 AQ�K�C�A'�� i� -Fti1.�. C:i'f'�- -- --- --- � � �_p3�--�.-"r'�f��G�Z�___-��'1 A�JG i rV t�'1�S_�A�f(L . _ -------------- u , I 1 , � I i ; i � Citation# 888 "°����$� ST. PAUL STATE OF MINNESOTA-RAMSEY DISTRICT COURT IIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIII)(IIII The undersigned, being duly sworn, upon his/her oath deposes and says: ( (IIIII IIII(II�_ * 8 8 8 7 4 3 2 8 5 * Date of Offense '�°` � � � / � "" Time of Offense � 1' ' °'�` �,, . :f p {� Plate �r ~ : Veh. License No. �..� � � � c.'�s Year � State �+ �{`_t�ake F � y�" ��A' � Style �`� �"`'`"" Color � e � r�.,- ,,, , 1 � ,-. t.,4 Location of Offense: � � ` ° VIOLATION: s�'� SNOW EMERGENCY St. Paul tJ��inance 161.03 FINE $53.Da (Amount includes mandatory state surcharges of$13.00 � � 1 �`{{ � t�"� � �� CN �`' I Citing t ,,,,,,�„_ ' Officer f '.., � Citing , � Officer Number Dept. C'�'f?o ted Night Piow ❑Day Plow �7Plowed in(?nJindrow) ❑Tagged Before Plow �Drove Ofi 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 ,� Saint Paul Police Impoun� Lot, 830 Barge Channel ��ad, vehicle ��lease Form � � Make: 99 HONDA License�#: XNlW�18 CPJ: 120470�4 Invaice#: 16867 Date/Time Released: 03/01/2012 12:39 7ow Charge: $ 123.95 Released to: TOTO Storage Charge: $ 0.00 � ; '1 ��.� w Paid by: CREDIT CARD Admin Charge: $ 80.00 Released by: BECKY Tax: (7.625°/4) $ 15.55 � �""". I,the undersigned,have recovered the vehicle de�crihed abave. Subtotal: $ 219.50 I will check the vehicle for damage or any other prob�ems .hat may have occurred while this vehicle was in the cust�dy of the Service Charge: $ 0.00 Saint Paul Police Department. I acknowledge I will report damage andJor any other problems to the Impound Lot staff Tota1 Charges: $ 219.50 on this form prior to leaving the impound lo±. Damage and/or other problem: __ ____ _ _ Police Report made: Yes_No_ IF Yes, CN_ , If NO, Why? TO PROTECT YOUR RIGHTS, REPORT ANY PROBLEMS/DAM�AGE BEFORE LEAVING THE LOT Signature _ , __ s�ZOOo ST PP.UL 1MFOUND LOT � C3� BFlRGF CHANNEL RD SAINT FRUI.. MP�. 551117-295F1 65]. l66-.642 MercF�ent ID: 96NG3?td14? � Tenn ID: F�N17>4f1UG4.3b�1G��<�144419 ' S�le zzzzxzzzzzxz812f � VIS� �ntrr Me�hod; Swiaed lota!; 4 219,5� 03�01�12 12:43,54 � Inv �; 000(�91 Appr Code; 207532 APprvd; Online Customer CoNv THANK YOU± �