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!�►'-
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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
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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±
�