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Torrel ��..i��1��.kl �� l,�G 1 � 20i2 NOTICE OF CLAIM FORM to the Ci�y`o#��int Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipality within 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 , -jO� Vf' 1 First Name L�.�U il I��(. Nliddle Initial�Last Name Company or Business Name Are You an Insurance Company? Yes/ o% If Yes, Claim Number? Street Address 4-�' �V �V I(�G(/l �'�/�� - City�`(Vl k'�.1�!-��/15 State �(�( Zip Code 5�9- I D Daytime Phone ( 1 - Cell Phone (�)�5Q-OZl l0 Evening Telephone�� - Date of Accident/Injury or Date Discovered `C�I�� 1� Time�_am pm 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. I�y�,� �,( �'V�1olS^�1/A V�l%iV� y yv� inJp �l d� a � - �� wa A ►.P( ' �r�v�� -t a s • � � si v-� � ve+� �� a °� �a � a �Pd L� inn Uvih� �' c� `.�- t,� � 8 Iz 5-25�r� �w� wl"' �•u��w ' Y-�� ► i . -� a � � u vvvv��l� 5`iy v►5 iNc°�P ��k�( PY��-t�,�j �J�oJrZ S 6v�_ b41� .� a� i�rn r �i �� su �� v� ti P�o - wo�X �.J i, � b�t:iV1o� P�61 5�'s ti�'�4'S�c 1 . —1"�^��n Y GU. _!l�,�e rn �?-k�1Av�cbS C�tvPviO� �es�.-► o✓tUv�v��ei�rTww�s Please che�k the" l�ox(es)that most closely represent the�eason 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 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 far 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 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? Yes � Unlrnown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes Unlrnown (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. 195h (.v� �� A��re � Y`-p��-� �-1 . � ��t v, 1 , Y�1 N 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. .��j�, '�(p— `��Dp-v(h�,,� )p-i �11 � Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year�_Make 6fGl Model 6'va c (a License Plate Number�yv,��j'� State �" N Color Registered Owner �' �y�� rY y P � Driver of Vehicle ��„�� d V Y�P I Area Damaged wYWt � � Cl2��i — Vfv �vua� 1c vPV�.i��p City Vehicle: Year Make odel � License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'ur Claims— lease com lete this section heck 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 you miss work? (provide date(s)) Name of your Employer: Address Telephone � �I�heck here if you are attaching more pages to this claim form. 1\Tumber 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_ � �'4• ��Z. -�. � Print the Name of the Person who Completed this Form: � ha � n� �"o�� P / Signature of Person Making the Claim: fjl,� ��/1X�C � Revised February 2011 Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form � Make: 09 TOYOTA License#: VZM753 CN: 12192694 Invoice#: 139425 Date/Time Released: 08/1 4/201 2 09:59 Tow Charge: $ 54.50 Released to: TOTO Storage Charge: $ 15.00 Paid by: CREDIT CARD Admin Charge: $ 80.00 Released by: SHANNON Tax: (7.63%) $ 10.26 � I,the undersigned,have recovered the vehicle described above. Subtotal: $ 159.76 I will check the vehicle for damage or any other problems that may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00 Saint Paul Police Department. I acknowledge I will report damage and/or any other problems to the Impound Lot staff Total Charges: $ 159.76 on this form prior to leaving the impound lot. Damage and/or other problem: Police Report made: Yes_No_IF Yes, CN , If NO, Why? TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT 5/2000 Signature 42 RLH FOW Appeal of Jacob Brunette, Relay Property Management, to a Fire 12-291 Inspection Correction Notice at 402 SIDNEY STREET EAST. 43 RLH FOW Appeal of Michael Salvati to a Fire Certificate of Occupancy Correction 12-292 Notice at 1697 WATSON AVENUE. City o/Saint Paul Page 4 Prinfed on 7/23/2012 Hotmail Print Message Page 1 of 4 Travel Documents for Emma & Mark's Wedding! From:P.Anderson(panderson99@earthlink.net) Sent: Sat 7/21/12 427 PM To: 'Shaina Torrel' (s_torrel@hotmail.com);'Akthode'(akthode@gmail.com) Hi Shaina&Kate, I hope you both had a good weekend! Below are your travel documents for the wedding!You must have them with you when you travel. Kate—I have the transfers set for you on the same flights as Shaina. If you are not on these the flights the transfer company must be told before you arrive or depart. Here is the number you call if you do not make the flight on 8/8 1-800-487-0740 to advise them you are not on the flight and what flight you will be arriving on. You have to call before the flight you were originally on arrives in Jamaica or they will void out your transfers. For your return on 8/13 if you are not going on the flight below talk to the hotel so you can change your transfer time. I hope this all makes sense. Please let me know if you have any questions. �.D E LTA Travel Documents VAGAT1037i ATTN:PSANll BOOklllg#: 12965403 Agenc,y: AMEX BURSCH TRAVEL pme�Aursch Tra�•el 320-251-31 RO 220 Division Street Type:Revised(Ol) N"aitr Park,biN 55387 PSAND Issued: 07i21/2012 TRAVELER INFORMATION Psgr# Passenger:�Tame Confirmation# E-ticket# Frequent Flyer# 1 Ms Shaina Elizabeth Torrel MEHLB7 0067017421346 DL 6928855490 2 Ms Anne Katherinerose Thode 222222 �� -� ► FLIGAT INTORMATION Date Carrier Flight# Class Departure City Departs Arrival City, Arrives 5tops Psgr#/Seat 08Aug12 Delta DL#2130 Coach Minneapolis/St.Paul,5:25 AM Atlanta,GA(ATL) 8:53 AM NS 1/28-A MN(MSP) Check in with Delta 08Aug12 Delta DL#0317 Coach Atlanta,GA(ATL) 9:51 AM Ivlontego Bay, 11:50 AM NS 1/31-A Jamaica(MB� 13Aug12 Delta DL,#0362 Coach Montego Bay, 3:00 PM Atlanta,GA(ATL) 7:01 PM NS 1/23-D Jamaica(MBJ) Check in with Delta 13Aug12 Delta DL#0300 Coach Atlanta,GA(ATL) 9:55 PM Minneapolis/St.Paul, 11:34 PM NS 1/19-A Page 2 of 4 Hotmail Print Message MN (MSP) You have purchased an elect�onic ticket(e-ticket). Government-issued photo I.D. is required and must match name on ticket.Your ticket number, flight confirmation number,and seat assignments(if selected) are on this itinerary. (If seat assignments were not selected,access your reseivation or contact your booking agent to do so.If seats are not selected,they��ill be randomly assigned at the airport upon departure).Boarding passes and boarding requirements may be obtained at delta.com Additional luggage fees may apply;learn more at deltavacations com/lu��a�e. SKYMILES BONtiS MIL�S Bonus Ivliles Thank you for making your'reservation with Delta Vacations.If you haee purchased a flight and hote reservation,you have qualified for bonus miles from Delta Vacations.To ensure you receive your bonus miles,your SkyMiles account nutnber must be applied to your reservation with Delta Vacations before you depart.(Bonus miles will not be credited to yow account if your SkyMiles number is provided directly to the airline.)If your reservation includes a car rental,please provide your SkyMiles account number at 2he rental cowiter to receive even more miles. Your bonus miles will be automatically credited to your account approximately 6-8 weeks after you return from your trip. If your acc�unt number has not yet been applied,contact your t��avel agent or Delta Vacations. If you are not a SkyMiles member,you can enroll at www.delta.com IiVIPORTANT INFORNIATION Change or cancellation Please cantact us or your booking agent to make any pre-departure cha�iges ar to cancel your reservation. Please Note We are not responsible for expenses incurred that were not booked as part of your package. All services are valid for use only on the date indicated.Hotel prices are intended for vacation travel.Individuals or groups attendizi�conventions may not use these rates.If a trip is for any reason other than vacation travel,some hotels may directiy assess an additional surcharge during conventions or special event iime periods. Documentation Notification Traveling outside the United States?International travel may require presentation of visas,passports,or other credentials.Make sure to check with the appropriate country's Consulate or Embassy well in advance of your travel date to verify what documentation is required.Laws and regulations regarding entry requirements aften change,so be sure to check the entry requirements each time Uefore you travc:l to an inteinational destination. Traveling«'ith Children FAA regulations require that a separaie seat be purcha.sed for a child who is two years of age or older.Wit proof of age,a child one year of age and under may legally be held on the lap of a passenger who is 15 years of age or older.For domestic travel,a birth certificate is acceptable proof of age.For international travel,all passengers are required to present a passport. Only one lap child one year of age and under,is allowed per adult.Tates and fees apply. Speciai Needs We would like yow vacation to Ue as comfartable as possible. If you have any special needs(wl�eelchair, medical,etc.)please have your boaking agent contact us in advance. ��.»,....--�;�n,� � __page 1 -- Booking#:12965403 �,t]E lTA Travel Documents v�cwfiia»s Passengers: (1)Ms Shaina Elizabeth Torrel,(2)Ms Anue Katherinerose Thode HOTEL INFORi'�1ATION Room Type Psgr# I Check In Check Out #of Nights Hotel � _ . . . .. ..... ..... „ � nin�innin Page 3 of 4 Hotmail Print Message � ALL 08Aug12 13Aug12 5 RIU Palace Tropical Bay-AI JrsSteOV Norman Manley Boulevard Negril, 876-957-5900 Confirmation�#: Confirmed Hotel rooms are usually available for occupancy after 3:00 pm.When you check in,please show this document. Check out time is at 12:00 noon.Be sure to check out with the hotel cashier and settle any incidental charges incurred.The hotel management is interested in your satisfaction.Please call the hotel's front desk if you experience any problems with your room. Includes: Rt Xfrs To/Fr Negril Hotels TRANSPORTATION INCLUSIONS: Roundtrip,shared-ride transportation between 1 1seirefer to the TRANSFER INFORMATION area of y ur h a v e p t u c h a s e d an u p g r a d e d�ehicle transfer,p travel documents.Transfers are provided between the Montego Bay Aiipor t a n d N e g ri l h o t e l s o n l y.T r ansfers are not available bet�reen hote ls. ARRIVAL INFORMATION: 1. After clearing Immigration and Customs,proceed to the at�rivals and transportation area located INSIDE o the terminal. 2.Look for our Destinais doEument e They are your off'cia�lLDest narion Expe•t�t m�in Jamaigca and��vill digect (located at the top of th ) you to your hotel transportation vehicle. DEPARTURE INFORi�7ATION: 1. Our Destination Exout of the hotel and be eady to departl foruhela rport 10 minutes prior�to yow'�cheduled 2.Please be checked pick-up time. DESTINATIOi�i EXPERT CONTACT INFORIVIATION: lease contact our official Destination If y�u require service or assistance of any kind while in Jamaica,p Expert,TOURWISE LIMITED at at 684-9566 in Montego Bay,at 974-2323 in Ocho Rios/Runaway Bay,or at 957-4228 in Negril.To compt�ou h our official De pi Zat on Expe ns They�n offer you a selection of the sightseeing tours and activrtie, g most popular activities in Jamaica,working with quality and reputable tour provider5 to ensure your satisfaction.Use caution when purchasing tours from any other source• If staying in Montego Bay,try the Irie Adventure Hor eback R ding n Ocho Rios and the Irie Adventure. tf staying in Ocho Rios or on the North Coast,try If staying in Negril or on the South Coast,try the South Coast Safari and Country Western Horseback Riding. Limited Time Offer Reduced'rates-must purchase by Apri130,2012. Limited Time Offer Book a Junior Suite Ocean Vie�v room for the same price as a Junior Suite Garden View rooin. Limited Time Offer Receive a$35 Spa Credit per adult per stay on RENOVA combination of RO muiutes. TItAVEL INSURANCE Psgr# Insurance Plan ALL Travel Protection Plan has been declined SPECIAL PROMOTIONS AiV�OFFERS Discounted Airport Parking Park��n�ir rar at TPam Parlrin�7�r Park'N Flv anri cavP nver riarkina�iirertiv at thP airnnrl TPam Parkina ie _ . . , ., �ri 1^�n_ 1 � ..� �1/ll/�/7/��7 Hotmail Print Message Page 4 of 4 most convenient for St.Paul residents aud Park'N Fly is best for those in Minneapolis and the southeni and western suburbs.Both offer covered,sectve parking and 24-hour shuttle setvice to the MiruleapolislSt.Paul aiiport,which is just minutes away.For more information,Visit deltavacations.com/airport To make a reservation,visit parknflynetwork.com/referrer/mlt.htm or call Team Parking at 651-690-1200. Discounted Airport Parking Park your car at Park'N Fly and save over parking directly at the airport. You'll also enjoy covered,secuse parking and 24-hour shuttle service to the airport.For more information,visit deltavacations.com/airport To malce a reseivation,visit Park'N Flv Park and Stay Special Offer Start yotu•vacation a night early at the Country Inn&Suites-Bloomington West conveniently located I-494 &Highwa5� 100 OR The Country Inn&Suites- Eagan located off of I-494&the Dodd Road Exit.A special Park&Stay rates includes one night lodging,up to 8 nights parking,and complimentary shuttle to both the Lindbergh and Humphrey terminals at the Minneapolis/St. Paul International Airport. To view Park&Stay rates, go ta www.deltavacations.com.For reservations at Bloomingtan West,call 952- 831-9595,for reseivations at Eagan,ca116�1-287-8800.Refer to code"MLT" to qualify for this special offer. Offer is based on availability and is subject to change. Private Airport Transfers Start and end your trip in sryle--and save 10%--with private,door-to-door trarisfers beriveen your home and the airport from Star Transportation.Vehicles are luxury sedans for up to 3 passengers,luxary SUVs far up to 5 passengers,and stretch limousines for up to 8 passengers.Visit deltavacations.com/aimort for complete inf'ormation and to make a reservation. CONTACT INFORMATION We want youi'trip to be tlioroughly enjoyable. If you need assistance before yoiu'vacation begins,please contact your booking agent. While enroute to your destination,please contact your booKing agent,or if your uoo':inD agen2 is not a�-ailabl�, please contact our 24-hom�Destination.Help Center at 1-R00-487-0740(available fiom the U.S. and Jamaica).To confirm your flight times,call the airline directly. For assistance while you are in Jamaica,or if you�-ould like information regarding reputable sightseeing tours, contact our official Destination Expert,Tourwise Limited,at 974-2323 in Ocho Rios/Runa��ay Bay,at 68�-9566 in Montego Bay ar at 9_57-4223 in Negril. Have a wonderful trip! Thank you, Patty Anderson Bursch Travel 952-937-2092