Eischens RECI�li�E[�
APR 2 6 20�2
NOTICE OF CLAIM FORM to the City of Saint Paul,�►�r�n��g��
Minnesota State Statute 466.05 states tlant "...every person...who claims damages frorrz arty municipality...shall cause to be presented to the
governing body of the municipality wit/Tin 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 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 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�tQh•�C� Middle Initial `-- Last Name �`5��h�
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address i�a q��h �� r1�
City p��\YY( State m� Zip Code ��_�r
Daytime Phone (�P�Z-) � �d I"i`��Cell Phone (���`�ID- ( �QEvening Telephone( ) -
Date of Accident/Injury or Date Discovered �u � —" o2C�� 2 Time �� �� ��f am�
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.
m �� n �,�o�S e�n � � •
' o r�e �.V�e
-� � � c c �
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 condition 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 youu need to include copies 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
ld'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—qlease comnlete this section
Were there witnesses to the incident? Yes No Unknown (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?�q L�C-� Case#or repart# �,�O�j 3 f� ��
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.5�lder� -�rc�vv�
qq 5 v�an5ldK� -�v�l hd o� `bo�'1 ei u.ror
Please indicate the a ount you ce seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction���3�5—
Vehicle Claims—please complete this section ❑ check box if this section does not apply
Your Vehicle: Yeaz 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
Injury Claims—please complete this section ❑ check box if this section does not apply
How were you in�ured?
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 I
Did you miss work as a result of your injury? Yes No '
When did you miss work? (provide date(s)) ��
Name of your Employer: I
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 41 ao f� a �o�
Print the Name of the Person who Completed this Form: �►a-+� �-1 S C�12{�S
�
Signature of Person Making the Claim: '��'Y`(�_��:`"�C��1`��1
Revised February 2011
Saint Paul Police impound Lot, 830 Barge Channei Road, Vehicle Release Form
Make:95 BUICK License#:436GWK CN: 12047044 Invoice#: 17240
Dat�me Reteased:03l42/201216:29 Tow Charge: $ 123.95
Releasecf to:TC}Tfl Storage Charge: $ 15.00
p���yy;Cqs� Admin Charge: $ 80.00
Re�eased b�li�iE!_tSSA Tax, (7.625°/a) $ 15.55
1,�u�e�i�aecf,i►ave recovered the vef�icte described above. Subtotat: $ 234.50
f w�e�eic�v��e for damage or arEy other problems that
rr��iiav�a�retf w�ti�e ffiis vehicie was in the custody of the Senrice Charge: $ 0.00
�t�ac�Pa�D�patfinent. t acknowfedge I will report
d�rna��stl/�any€ttf�er pr�lems to ttte tmpound Lot staff Total Charges: $ 234.50
c�rt th+s fa�rrf �-�ar tc►�a�ing#he impound Eot.
ETaimac,�artt#far c�ifiter p€ot�em:
Po�R�rt made:Yes_No_IF Yes, CN , If NO,Why?
�C�RR{3TECT YOUR RIGHTS REPORT ANY PROBLEMSlDAMAGE BEFORE LEAVING THE LOT
Sigrta�re ��
.., . — --_..
_._�..�_._._�_.�_.��_.�_._.._.__�.__.__�...,�_�...�__�.__�...�..�_,_.._�_...._a.�..,.�..�_,�.._..�..._._A�_��..�.�_..,._,.o...�.__,�.....� �.�i
' Citation# 8$$ ���, ��Q.�
' � ST. PAUL
STATE OF MINNESOTA-RAMSEY DISTRICT COURT I�I
�I��� �
. � � � .
The undersigned,being duly swom,upon his/her oath deposes and says• .
* 8 8 8 7 5 1 1 4 6 *
Date of Offense � � Time of Offense ' '
P1ate -d' ' } _
; _ : Year State ' ; Make . . , Style Color . , ,
Veh.License No. `
_ . ,r
Location of Offense: x • t .
VIOLATION: SNOW EMERGENCY St. Paul Ordinance 161.03 FINE $53.��
(Amount indudes mandatory state surcharges of$13.00)
;
CN
Ci6ng Officer Citing
��� Number Dept.
❑Posted Night Plow ❑Day Plow �}•Plowed in(Windrow) ❑Tagged Before Plow �Drove Off
OFFIGER'S NOTES
�NO PLATE VIN:
Citation can be paid at the Impound Lot Please read the back of the citatio�for paymeM instructions.
CITATION
. ,
avoid this unnecessarY expense and frustration. We hope you find the information below helpful.
Page 4 of 5
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Date and Time of Aeport
Cwr►plaint Number Reference CN Q2/1?/2012 09:59:00
12033��7
Pr�mary offense:
AUTO THEFT-AUTOMOBILE
PROPERTY
ITEM#t �ocarion�osr. 995 Vanslyke
Type of loss: $tOletl Date of Loss: 2/1 y2012
Date Recovered: Locatlon Recovered:
owner.• Eischens, Diana Lyn Serial#: 1 G4AG55MOS6439011
Mode�#: Century Quantiry: 1
arnc�e ryQe i item: Other property
/ VehiCle Tota'value: $1,000.00
Description: v@h.436GWK
Tumed in at:
Locker 1D#: Lab exams:
VEHICLE INFORMATION (Property)
Status ���jO�
License no.: 436G W K Y�r 1995
starus: Stolen rype: Sedan
rowed.• No stat�: MN
Year: 12/2012 �b�� Blue, Light
Lock siatus ��: 4
poors unlocked: V.►.N.: 1 G4AG55MOS6439011
Make: BuiCk rransmisston: AutomatiC
rgnmon uMocked: snm Posirron: Column
Trunk uNocked: M«fe�. CENTURY
Keys in vehicle: NO Mileage:
Msurence�owr�er InMrmstlon
Vehicfe conteafa dF drlver
tnsurance co.: NONE Keys in vehicle: NO
Lienholder: Owner allowed someone to
use vehicle:
Lease Company:
Stolen Method:
Amount Owed:$0
Theft Coverage:
Registered owner. EiSChens, Diana Lyn
Drive►s iicense no•: E252143564037
Personal property in vehicle:
Participants: Address: Phone:
Person Type: Name: 612-532-3621
Complainant Bradt,Ashiey Marie 5609 35TH AV S
MINNEAPOLIS, MN 55417
Suspect �
II�IIIIIIIIIIIIIIII�IIIIIfII�IIIIIIIIIIIIIIIIIII�I�II1 INCIDENT INFORMATION REPORT 4/20/20121
STATE OF MINNESOTA
COUNTY OF RAMSEY
DISTRICT COURT
INCIDENT AND CtTATION INFORMATION
INCIDENT ID PAYMENT PLAN CITATION NUMBER
2321407 888751146
DEFENDANT NAME DIANR LYN EISCHENS
ADDRESS 162 97TH AVE NE
BLAINE MN 55434
DEFENDANT INFORMATION
DATE O� BIRTH 1/13l1973 GENDER
HEIGHT EYE COLOR
WEIGHT DRIVERS LICENSE DL STATE
RACE HISPANIC (Y/N)
OFFENSE INFORMATION
DATE/TIME 03/01/2012 14:14 DIVISION RAMSEY COUNTY
LOCATION IFO 807 AURORA COMMUNITY ST PAUL
METER AGENCY PUBLIC WORKS
OFFICER 1 744
OFFICER 2 CCN 12047044
NBRHOOD
VEHICLE INFORMATION
PLATE 436GWK MAKE BUICK
STATE MN . MODEL 4 DR
YEAR 2012 COLOR BLUE
VIN 1 G4AG55MOS6439011
RESPONSIBLE PARTY ID METHOD
NONE
OTHER SYSTEM IDENTIFIERS
CN NUMBER
CHARGE INFORMATION STATUTEI
STATUS REASON JURtSDICtION ORDINANCE DESCRIPTION
CtOSE STLN STPAUL 161.03 Snow emergency parking restrictions
ORIGINAL FEE INFORMATION AMOUNT DUE
$40 FINE 40.00 $40 FINE .00
LATE FEE 5.00 LATE FEE .00
Srchrg-2nd District 1.00 Srchrg-2nd District .00
Srchrg-Parking 2009 12.00 Srchrg-Parking 2009 .00
GRAND TOTAL 58.00 GRAND TOTAL .00
OFFICERS COMMENTS
PLOWED IN (WINDR01/�