Sanders �����v��
MAR 2 � 2f�12
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
��°�''�' ���.�����:
Minnesnta State Stat�ite d66.05 states that"...every person...wh�claims dnmages frorn atv municipalitv...shall cause to be preseftted to the
gnverning bndy of the muriicipality within 180 days after the al[eged fnss or rnjury is discnvered a notice stating the trme,place,and
cira�mstances thereof,and the amourit of canPensation or other retief deneaRded."
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 We
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 L-•Q.n1� Middle Initial S Last Name �G.Y�C�2N��
Company or Business Name
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Address �..�?7 lJJ!'1G�Q,SS S�P� ���' /�c
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City SA,l V1�`�Ou� State t�lt� Zip Code 55101
Daytime Phone( 51 '�1�-5501 Cell Phone{31� )�3-319q Evening Telephone( tl )�_-5�L
Date of AccidenU Injury or Date Discovered ��►Y`C� \q.'21J\1 Time 1•'l� am�
Please state,in detail, what occurred(happened), and why yon 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.IJJQS Duk� 0� �Wr1�.C�e.
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Please check 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 condirion of the street ❑ My vehicle was damaged by a plow
$(My vehicle 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 vou need to include copies of all annlicable 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 andlor 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
andJor 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 claun.
All Claims—please comnlete this section
Were there witnesses to the incident? Yes No Ilikno (circle)
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 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. � `L04 .1�
Vehicle Claims—nlease complete this secNon �check box if this section dces not annlv ,,
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section �check box if this section does not anvlv
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(sj:
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 3 .
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.
Submilling a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Complete�l this Fo � ` � �
� � �. ;
Signature of Person Making the Claim: ,�� �� �
Revised February 2011
Saint Paul Police Department Pa9e ' °f2
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Comp/aint Number Reference CN Date and Time of Report
12060306 03/20/2012 14:08:00
P�imary oSense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE,HIT & RUN .
Primary Reporting 0/ficer. Burke, StU81"t C Name of locatfon/business:
Primary squad: Location of incident:CONGRESS ST E& ROBERT
Secondary reporting officer. ST PAUL, MN 55107
Approver:
as��Central Date&time of occurrance: 03/15/2012 17:05:00 to
S�e� 03/15/2012 17:15:00
Arresf made:
Secondary offense:
Police Oficer Assau/ted or Injured: Police O�cer Assisted Sulclde:
Crime Scene Processed:
NARRATIVE
I, Sergeant Burke, was assigned the follow up investigation into a Hit& Run accident that occurred on
3/15/2012. Squad 236-Officer Kunde reported that a Dodge Caravan, MN license SNJ-963, driven by Fatuma
Haro Wako, was S/B on Robert, at Congress, when it was rear-ended by a "newer model green Ford
Explorer," partial license plate MN 773. The Explorer fled the scene. The person reporting stated a third
vehicle stopped and the passenger picked up the front plate that came off of the striking vehicle.
Later that day, the complainant Abdusalem Nasiro Mohammed, called and reported that he thought he had
found the vehicle involved in the hit and run on the parking lot at Congress and Anita. At that location, Officer
Kunde found a 1996 Ford Explorer, Eddie Bauer Edition, green and tan paint, bearing license 640-HWW on the
rear of the vehicle and the front plate on the dashboard. Mohammed stated it was the vehicle he remembered
striking his car. Officer Kunde noted..."the partial plate MOHAMMED initially provided differed from the plate
displayed on this vehicle, however at the time of the initial call, MOHAMMED was still very shaken up from the
crash and worried for his family, and was not certain of the partial plate he provided."
Officer Kunde noted that"...the Ford had front end damage consistent with striking the second vehicle
involved." The Fo�d Explorer was towed to the Impound Lot with a "hold" placed for Traffic&Accident.
On 3/19/2011, I received a call from Miesha Martin-Freeman who stated that she and her husband, Leon
Sanders, had just retumed from vacation and their car was missing from their parking lot. Their car was the
Ford Explorer, MN license 640-HWW. The vehicle was listed in the DVS web site as "Not on File." Martin-
Freeman stated they had recently transferred the registration from Louisiana to Minnesota. She contacted the
police department and was told the car had been towed and that she should contact me.
According to Martin-Freeman, they left town, on Wednesday, 3/14, flying out of the Minneapolis-St Paul airport.
No one else had a key for the car and no one had permission to drive the vehicle.
1 reviewed the reports and found much conflict with what appeared in the original report and the follow-up by
Officer Kunde. The license plate information was conflicting. The vehicle was described as a "�ewer g�een
Ford Explorer." The Ford that Mohammed led the officers to is a 1996 model with a distinctive green and tan
Saint Paul Police Department Pege 2 °'2
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and rme of Report
1206Q3Q6 03/20/2012 14:08:00
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE,HIT & RUN .
paint theme. I advised Martin-Freeman that I would go to the Impound Lot and check out the vehicle, but it
appeared the vehicle may have been towed in error.
I went to the Impound Lot and inspected the vehicle. The paint is faded and the vehicle looks old. The interior
is in poor condition, with the leather on the seats cracked and torn. The ignition switch was intact and there
were no signs the vehicle had been stolen. I examined the front bumper of the vehicle. There were no signs of
recent damage to the front bumper. In fact, the front bumper and bumper cover is in very good condition for a
15 year old vehicle. There was damage on the left front comer of the bumper, but it appeared to be very old.
The metal area was scraped and �usted,but obviously very old damage: tn my opinion, this vehicle showed no
indication of being involved in this incident.
I released the Hold on the vehicle.
I contacted Senior Commander Pye to request the vehicle be released to the owners without being charged
any of the related fees. I was unable to get confirmation from Senior Commander Pye before the owners
retrieved their vehicle, due to their immediate need for the vehicle. After explaining the situation to Senior
Commander Pye, he was in agreement with the release of the vehicle.
PUBLIC NARRATIVE
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