Micheletti (2) State c�f Minnesota Conciliation Court o
Ramsey County �� �� � �� ��econd Judicial District��_� �—� Case
r-IL�D
STATEMENT OF CLAIM AND S�Q�TS
Plaintiff#1 Plaintiff#?�(J
Name: State Farm Mutual Automobile Insurance P Name
c/o Kelly B.Micheletti E Address ` ` '
Address: 220 S.6 St.#2050 p pe , �
City/State/Zip: Minneapolis,MN 55402 S City/State/Zip
VS. E VS. " �
Defendant#1 P Defendant#2
Name: St.Paul Fire Deparhnent R Name: City of St.Paul c/o City Clerk
Address: 25 W.4th Street I Address: 15 Kellogg Blvd.West
N
T
City/State/Zip: St.Paul,MN55102 City/State/Zip: St.l�raul,MN55102
PLAINTIFF'S STATEMENT OF CLAIM
�1. The Defendant(s)owe(s)me$1,372.76,plus filing fees and costs of$75.00,for a total of$_1.447.76_
because(state what happened and when it happened):
On or about May 19, 2011, Defendant St. Paul Fire Departrnent drove failed to properly contain equipment while
operating a vehicle owned by Defendant City of St. Paul. T'heir actions caused damages to the motor vehicle
owned by Plaintiffls insured, Joseph L. Schwab. As a direct and proximate result of Defendant St. Paul Fire
Department's negligence, PlaintifF and its insured were damaged in the amount of$1,372.76. Defendant City of
St. Paul is liable for the damages as the owner of the vehicle pursuant to Minn. Stat. § 169.09 subd. Sa. Plaintiff
seeks reimbursement pursuant to its right of subrogation.
�2. The Defendant(s)has/have the following property that belongs to me(list property),, valued at,
$ ,plus filing fees and costs of$ , for a tota.l of$
I want the Court to order this property returned to me or make the Defendant(s)pay me money for the value of
the property.
3. I believe the person(s)I am suing is/are at least 18 years old and not in the military service.
4. I understand that if I do not come to court on my hearing date,my case will be dismissed and I may have to pay
money to the Defendant(s)on any counterclaim that has been filed.
NOTARY STAMP OR COURT SEAL SWORN TO BEFORE ME ON: TI�ABOVE STATEMENT OF CLAIM IS TRUE AND
n� ln ' n CORRECT T T RESTRF I}Q� I WLEDGE �
KATHERINE ROSE GREN�LL Date:��_L�J IT f�i� // Signature: � U�l1J ' O
NOtBry PubliC "�1�4L1-4C����... atne: Kellv B. icheletti
Min�lesOte Signature: itle(if representative):Attomev for Plaintiff _�
' � 31.2016 elephone: _(612)338-6000 ^ ,
Our file#: 6161S-10010 � t
Notice of Settlement - �
The above-entitled case havin�been settled,the same may be and hereby is dismissed with my consent. �
�
Date: Plaintif�'s Signature: 1_
SUMMONS: IMPORTANT NOTICE TO THE PARTIES
You must come to court for a hearing on 2, 2 at (�: � .m. at
Location/Address
If you do not come to court for this hearing,you may lose the case and have to pay money to the other
party.
Dated: (p� • � 2 Court Administrator/Deputy 5 ' 2(�I�0' �2 3�