Jacobsen '����.4����
NOTICE OF CLAIM FORM to the City o��� �aul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any muni�ality.,.sh�z11 cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is���iverErd a��tice 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 ezplain your claim,and the amount of compensation being requested. You will receive a
written aclrnowledgement 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 ` Middle Initial�Last Name ��dt.(���ic��
Company or Business Na e--' �—
Are You an Insurance Company? Yes��If Yes, Claim Number? <-- `
Street Address �� � {�j��'c�- �� ���;�'.�—
City J �J� State �� Zip Code �
_._ __ Daytime Phone����(9-�.!�C;ell Phone ( ) - _ _ Evenin Tel hone
g eP �— -
Date of Accident/Injury or Date Disco'ered_�i� . 'L��?i Time�_air 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 P ul or its employees ar,e�involved and/ar responsible for your damages. � �h
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Please chec t e bo��at most closely represent the reason for completing this�orm: -�� ��.i.� �
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a����"
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ��
'�i�Iy vehicie was wrongiully iowea and�'or ticketed ❑ 1 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 ar it will delay the handling of
your claim. Documents�TILL NOT be returned and become the property of the City. You are encouragec�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
�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
andlor 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-ulease complete 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 To Unknown (circle)
If yes,what department or agency2 Case#or report#
Where did the accident or injury take place? Provide street address, cross street, intersection,nam�of ark or facility,
�losest landmark, etc Please be as d ta}'le�d as ossible. If necessary, attach a diagram. � a� �'1 .�� �
I �_.r,.�,�1n..�r�� �Cl/Li I'��V i .�
Please indicate the amount you are seekin in compensa 'on or what you would like he ity to do to resolve this claim
to your satisfaction. ILf� �
, �.
Vehicie Claims- Iease com lete this sechon ` ❑ check box if this section does not a 1
Your Vehicle: Year�� �Make � Model
License Plate Number y,ll�,1P�� State M,N Color .� I� ��_
Registered Owner `�
Driver of Vehicle
Area Damagec���- �
City Vehicle: Year Make ___ Model _
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Iniury Claims-please complete this section �eck box if this section does not apply
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
i 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�.
�
By signing this form,you are stating that all inforrrtation you haveprovided 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 g �
Print the Name of the Person who Completed this Form: +�G f.0
Signature of Person Making Yhe Claim:
Revised February 20ll -
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State of Minnesota � Ramsey District Court
ci�r oF sai►�T Pau� '
PARKING CITATION �
ChatlonNo.� gZ09��6�4�� �
�...No.: `� �� ��IAI. 1 M�o 1�ND l,�'f ��
St.Paul Police Department
�, �.��,
e3UrBAitt;E�i HAl�tit L RU �—
V�hich Llc�nss Numbrr: YUYB4Z statr.NJ USA SAINf PAUL. MN. 5b'14f�-246u
V�hlcls VW: 65: 16G cif,4't
Make:VOLKSWAGEN Modd�:PASSAT Color.GRAY Merc.ne��2 io• '�bsa�l-i9
Typ�:PASSVEH Tc��m lU: E1tI1T340C�4fFlkcEtli636U'.44�10
Tab Month: T�b Y�v: Ju 1 e
Oets of Offsnas 811412012 Tlms of Ortenee 0$:25
StdutNOrd ORsnse XXXXX;(XXXXXXS�UJ
- - 4BB.�4.1(a{E1A}PARK VYFIERE BIGN8 PROHIdIT . __ -- - VI�� Cp�fY MQfhOd, Swiped
iotal: � 144.7=_
.___..
��ail4ii2 16:��:4i
�r�u �; 0�i�16 RPPr Codr: �1436D
�u�;:��. Or�line
c��7t��,��� c„ur
� I IIANI( Y011!�
Olfms�Locrtion:
876 LINCOLN AV Intsnwtinp Stro�t:
2ntl Cross Stn�t � . . - � �
OR�ns�Cky:
St.Paul
MsterNumbsr: PsrmitZons: SiynsVls:
Chalk In: Chalk Out; ParK�d: (HH:MM) Tlms Zons:
Untt:9zw
orticer�:PEO M.Jones
Olflur Number: 327831
ORlc�r 2: .
Olflcer Number:
Report defective meters by noon the next business day
Cbll(651)288•9778
To pay your Me by credit card,wait 3 business days and then call
(851j 288�B2d2
f citstl tor No Proolof Ineurence or No Orivere Llsenea in Posseesion,Proo(oi Inauranes anNor __.__ .. _ __.
Drlv�n Linns�ahould b��hcwn in on�of th+Viol�tlom 8unw Locat�on�u�t�d b�Iow withln
21 buslnsse days otthe vlolrtlon. �
Topeyyourcitatlononlln�: www.4ndwsbeal+.courts.stnte.mn_.ua
For�ddltlonal intormation or to pay your fln�by t�l�phon�usin0 a credit card,
CSfI: {661)288�202.
Plea9s havs your citation numb�r and ondit card avallabl�.
Mail paymsntc to: Ramsey Dlstrict Court
TraRlc Violatlons Burexu
76 Wsst Kellopp Boul�vard-Room 130
St.Paul,MN 66102-7613
Meke checks payable to: Ramaey Olstrict CouR , �
(p chvp�of up to;30.00 w���b�aas�s��d on dl r�turn�d ch�cksl
Violetiane 8ureau LocsHans .
3t.Paul Court Suburben Court Law Entorcement Center
16 W.Ksllopg 61vd.RM 190 4060 Whlu B�er Av�. 426 Grow 8tr��t
6t.Pau�,MN 6610Z Meplewootl,MN 66109 St.P�1,MN 66701
Oftic�Hours:8:00 A.M.-4;30 P.M. Monday-Fridry(Excludlnp Holidayal
Heu'iild ORlters:8y appoir�tmbnt o�ily cill i�i1)-288�202
Payment a�d Penaldes
If you wi:h to plad puifty for th�oQense(s}on the nwn�alds of th�citetion,You mu�t do�o
within 29 tlays from thr dste tha clttdion le Bletl wlih tHa Court.It la your rsrponsibllRy to
pn�mt your prymmt n a tfmdy mann�r.P��u�Nlow 6 busim�o d�y�for proc��sinp.A W.00
th�Court�ddi tlond ddinqwnt f�s m■y b�add�do dl unDdd fln��mount�stion Is flUd wRh
Additlonel peneRiae may includs:1)roisrrd to the D�partm�nt of Publle Sdsty for driwr's
Iluns��usp+naion,Zj�rn�t w�rnnt luwd,�ndlor 3)nf�rnl to a coll�ction��p�neY�
If the o8eme is a p�try misd�m��nor,►alWrc to app�ar will b�consid�red�pl��of pullty and
walvar to ths ripht to trlal unlnss the fallurs ta appaar ia dw ta aircumet+nces beyontl ths
p�non`s contrcl(M.6.16�.911.
Appeal
To plsed not yuitty,or to plsad pullty and oRer an saplenation:
1�AR�r 3 businns Ery�,cdI 66i-266$1��to conilrm that th�cRatbn hu b��n fUed
wkls thi court.
2)If th�citallon hu b�en Nad,rrquest�hnrinp ofllnr�ppolntmmt.
9}WH+n you i�rrivs ft th�Vialatlon�Bureau,bll the cashler that you hws a heerinp .
otRc�r�ppointm+nt You must h�ve r photolD with you. _
I und�rst�nd that by PAYING THIS fINE i AM ENTERING A PLEA OF(SUIITY to this of(ma�(al
uid voiuntarily walve ths fallowinp ridht to:
A.a trial to ths court,if ofFense ie a petty miedemsanor, .
B,a trid to th�court or tc�lury Itth�otfms�I�a miad�m��nor, i
C.rapresentatlon by aounasl, �
D.a pnsumptlon of innoc�nc�untll prov�n pufftY beyond�nasonable doubt,
E.tor�ffont�nd cross-examina ell witnes�ea spalnst m+,�nd
F.+Ither nmdn slbnt or to tntly in my omt b�h�H.
I also undent�nd that if this aff�ns�is a pectY mi�dsme�nor,th�mazimum possibl�s�nbnn is
s30p.00;if fhle oRenar la r mi�tliMSanar,the maYitnum pots�bls asnGnee is=1,000.00 fln�
rnd/or90 drys lmprl�onm�nt.
citatlon No.:620900604641
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