Guerra f��G�!'��i�
�UN 2 c� �;�1?
NOTICE OF CL�IM FORM to the City of Saint/P� au1,�lVtinnesota
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Mi�inesota State Statute 466.05 states that " ...every person...who clainTS damages from any municipalit��...shalt cause lo be p��eserited to the
governing body of t/ze municipaliry wit/iin 180 days after t/ze alleged loss or i�2jury is discovered a notice stating tlie tinie,place,and
circumstances thereof,a�zd 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 acicnowledgement 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 '�O: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PALTL, MN 55102
First Name �( �( }� Middle Initial Last Name �( �T(��
rnr„�,anv nr Rusiness Name
Are You an Insurance Company? Yes/No If Yes, Claim Number?
;
Street Address �� � � ( ����i�_� }� ��
City �� ��(� l State � � Zip Code ~ j� �
Daytime Phone (� - Cell Phone (����-� ��, �Evening Telephone (_) -
Date of Accident/Injury or Date Discovered ('�� �� � ����� Time � ���'� ar�,/pm
�
Please state, in d,:tail, v,�hat 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.
.�-,
� _ � -�-� ' � _
�
Please check the box(es) that most closely represent the reason for completing this fonn:
❑ 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
Ll My vehicle was wrongfuliy towed anii/�r tickete ❑ I�.�ras ir.jured on C;?y pm erty `
� Other type of property damage—please specify �} �1)i lJ� XS� ea� (.ebt�� (�if� C2���'S0 ��` _
❑ Other type of injury—please specify
In order to process your claim you 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
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
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
_�.i
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section
Were there witnesses to the incident? �e� No Unlrnown (circle)
Provide their names, addresses and telephone numbers: � , c = �- � '� � �y iC�f
�;����GC `�
Were the police or law enforcement called? Yes No Unlrnown (circle)
If yes, what department or agency?i`,�„�.�c,t�1,�� C��let1 q�1 Case#or report# ��(y�(�;y�
Where did the accident or injury take place? Provide street address, cross street, intersection,name of park or facility,
losest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram.�� h��
� �1 � �a
���,�a�-�� A�� � � 1�� I�1��! � �� �
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.s �
Vehicle Claims please com�lete this section Qf check box if this section does not apply
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_
I In'ur Claims— lease com lete this section f� check box if this section does not a 1
� 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 vou miss wark? _ (provide date(sl)
Name of your Employer:
Address Telephone
I� Check here if you are attaching more pages to this claim form. Number of additional pages�.
By sig�ii�zg this form,you are stati�zg tliat all i�zformatio�z you have provided is true a�zd cort•ect to tlze best
of your knowledge. U�zsigned forms will�zot be processed.
Submitting a false claini caiz result i�z prosecution. Date form was completed 4�Yg - �tG" c�V ��
Print the Name of the Person who Completed this Form: f'�� ' I � e`�� — �
�,?, .
Signature of Person Making the Claim: � ��
Revised February 2011
1 i�� �,vu�l�y �cudu L
Maplewor�d MN 55109
651-`�70-8100
CUSTOMER SERVICE: 1-$00-482-7512
www.slumberland.com
NUMBER: 0624208WZI
SIXTO GUERR.A ORDER TYPE : SAL STAT:O
46$ ARLINGTON PL PICKUP: ZONE: Wl
ST. PAUL NIl�T 55130 DATE: 06/24/12
H/P: 651-894-3270 B/P: 0 SALESPERSON: JOSSPH JWMS
CUSTOMER CODL: GUERS468Z4 SALESPBRSON:
------------------------------------------------�--------------------------------
--------------------------------------------------------------------------------
QTY LOCATION SKU NO. VEND VSN/DESCRIPTION PRICE EXT. PRICE
_--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
1 1. 00 08 1262420 ARTE L12624 VALLTE PR�GRAM
DON T LOOK BACK 99. 99 99 . 99
2 1. 00 08 1262374 ARTF L12623 VALUE PROGRAM
SHE SAID DON T FORGET . 00 . 00
3 1. 00 PRICING FOR PURCHASING PACKAGE GROUPING
PRICE REFLECTS GROUP DISCOUNTS .00 .00
DEP TP DEP AMT Approval Code: SUB TOTAL: 99 . 99
------ ------- Other CHG: . 00
BC 107. 11 TAX: 7. 12
TOTAL: 107 . 11
DOWN PAYMENT: 107 . 11
ACCOUnt Number FI AM�UNT: . 00
FINANCE COMPANY: BALANCE DUB: . 00
FINANCING T$RMS: By signing below, you acknowledge that this transaction is
under your credit card account agreement with
(flthe Bank") . You give the Bank a security interest on any goods purchased
in this transaction, if financed. You also acknowledge receipt of a copy
of the Disclosure of Regular Annual Percentage Rate °APR" which was provided
to you as a separate dacument along with this invoice.
SIGNATURB
_-__-=�==Please call 651-482-0926 at least one day prior to pick-up.====_______
thank you!
.
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Page 3 of 5
Saint Paui Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complainf Number Reference CN Date and Time of Report
12142647 06/18/2012 11 :51 :00
Primary offense:
INVESTIGATE-ASSIGNED TO CRIMES AGAINST PROPERTY
Phones
Home: Ce11�651-89�1-3270 Contact:
Work: Fax: Pager:
Employment
Occupation: Employer:
Identification
SSN: License or ID#: License State:
Suspect
UNKNOWN
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details
Sex: Race: DOB: Resident Status:
Hispanic: Age: from to
Phones
Home: Cell: Contact:
Work: Fax: Pager: �
Employment
Occupation: Employer:
Identification
SSN: License or ID#: License State:
Physical Description I
US: Metric:
Height: to Build: Hair Length: Hair Color:
Weight: to Skin: Facial Hair. Hair Type:
Teeth: Eye Color: Blood Type:
SP000002568E29F4
Page 2 of 5
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
12142647 06/18/2012 11 :51 :00
Primary offense:
INVESTIGATE-ASSIGNED TO CRIMES AGAINST PROPERTY
Employment
Occupation: Employer:
Identification
SSN: License or ID#: License State:
Other Johnson, Bradley Alan
MN
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details
Sex: Male Race: W;�ite ��8� 12/t4/1954 ResidentStatus:
Hispanic: Age: 57 from to
Phones
Home: Cell: Contact:
Work: Fax: Pager:
Employment
Occupation: Employer:
Ideniification
SSN: License or ID#: License State:
Owner Guerra, Sixto
468 ARLINGTON AV E
MN
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details
sex: Mate Race: DOB: 2/21/1 Q$1 Resident Status:
Hispanic: Y2S A9e: 31 from to
SP0000025BSE29F4
Page � of 5
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
12142647 06/18/2012 11 :51 :00
Primary offense:
INVESTIGATE-ASSIGNED TO CRIMES AGAINST PROPERTY
Primary Reporting Officer: Byrng, Christopher M Name of location/business:
Primary squad: 353 C.ocation of incident:468 AFiLINGTON AV E
Secondary reporting officer: ST PAUL, MN 55106
Approver: CheShi61', Patrick
�istricr: Eastern Date&time of occurrence: 06/18/2012 1024:00 to
Site: 06/18/2012 11:58:00
Arrest made:
Secondary offense:
Police Officer Assaulted or Injured: Police Officer Assisted Suicide:
Crime Scene Processed:
OFFENSE DETAILS
INVESTIGATE-ASSIGNED TO CRIMES AGAINST PROPERTY
Attempt Only: Appears to be Gang Related:
Weapon(s)Used
Hands/Fists/Feet
NAMES
Other Finn, Bradley
MN
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details
Sex: Male Race: White
DOe: �2/�4/1954 Resident Status:
Hispanic: Age: 57 from to
Phones
Home: Cell: Contact:
Work: Fax: Pager:
SP000002568E29F4
Saint Paul Police Department Page 5 of 5
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
12142647 06/18/2012 11 :51 :00
Primary offense:
INVESTIGATE-ASSIGNED TO CRIMES AGAINST PROPERTY
Suspect
NARRATIVE
Squad 353 Byrne was sent to 468 Arlington Ave. on damage to comps window by the City of St. Paul Parks
lawnmower.
Met with homeowner, Sixto Guerra 02/21/1981, who invited me inside to show me the second story window. It
looked as if it had been shot out, however, he showed me the bolt that his wife found on the floor. When Sixto
looked through the window he saw two parks employees cutting grass at the field across the street. This bolt
was apparently shot from one of the lawnmowers through the window and into a framed picture hanging in the
hallway. The print was damaged along with the glass.
Squad 350 Jones took photo's of the damage and the bolt. The bolt was turned over to the parks employees.
PUBLIC NARRATIVE
Squad 353 Byrne was sent to 468 Arlington Ave. on a damaged window. On scene owner had St. Paul Parks
service looking at damage from their lawnmowers.
�:��„
SP0000025B8E29F4
Page 4 of 5
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
12142647 06/18/2012 11 :51 :00
Primary offense:
INVESTIGATE-ASSIGNED TO CRIMES AGAINST PROPERTY
Offender Information
Arrested: Pursuit engaged: Violated Restraining Order:
DUI: Resistance encountered:
Condition:
Taken to health care facility: Medical release obtained: `
f
SOLVABILITY FACTORS
Suspect can be Identified: By�
Photos Taken: Stolen Property Traceable:
Evidence Turned!n: Property Turned In:
Related Incident:
Lab
Biological Analysis: Fingerprints Taken:
Narcotic Analysis: Items Fingerprinted:
Lab Comments:
PROPERTY
ITEM#1
rype of�oss: Dam aged Date of Loss: Location Lost:
owner: Guerra, SIXtO Date Recovered: Location Recovered:
Model#: Quantity: Serial#:
Article Type/Item: Othel'pl'Operty / Household items Total value:
�escription: Screen, glass window, picture on wall
Turned in at: Locker!D#: Lab exams:
Participants:
Person Type: Name: Address: Phone:
Other Finn, Bradley
MN
Other Johnson, Bradley Alan
MN
Owner Guerra, Sixto 468 ARLINGTON AV E
MN
SP0000025B8E29F4
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�� EX�'.ERIORS Superior Development, Inc.
MN Contractor #20219220
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