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NOTICE OF CLAIM FORM to the City of Saint Paul��$'��a
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 ofher 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 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, 5AINT PAUL, MN 55102
First Name �/�i' Middle Initial�Last Name (�1���(�/S�
Company or Business Name
Are You an Insurance Company? Yes/ If Yes, Claim Number?
Street Address �S S O�� T �
City �{/� State Zip Code �� /��
Daytime Phone(� - Cell Phone(� �S�/ y �� ening Telephone�) -
Date of Accident/Injury or Date Discovered Lb —� Z — C Z— Time��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 andlor responsible for your damages.
� �
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
❑ M�vehicle was damaged by a pothole or condition of the street ❑ My vehicle was daxnaged 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 WII..L 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; ar the actual bills and/or receipts for the repairs
�'Powing 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? es No Unknown (circle
� Provide their names addresses and tele hone nu bers: l� rJ
, P
✓�� h c� �iv.
�o
��n 2 �o �,��..(a �1
Were the police or law enforcement called? Yes No � Unlrnown (circle)
If yes,what department or agency? ` �ase#or report#
Where did the accident or injury take place? Provide street address, cross street, intersection,name of park or facil'�,
closest landmark, etc. Please be a[�detailed as possible. If necessary, attach a diagram. /��. Si�SS,� Do• ' v�
� p(�� Ci✓�d� S yif.ZQ T•
Please indicate the amount you are seekin in compensation or what you would like the City to do to resolve this claim
to your satisfaction. . •
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year 2t� a Make Model N��
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
In,�urv Claims-please complete this section c eck box if this section does not applv
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
-----��'r�di�5�au tniss���?- — — _. -- - (��'c,�3��)
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 information you have provided is true and correct to the best
of your knowledge. Ilnsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed D - 2 � ( L
Print the Name of the Person who Completed this Form: 2 �'/ G,� 5 �
Signature of Person Making the Claim: --
Revised February 2011
State of Minnesota Rameey Diatrict Court
CITY OF SAINT PAUL
PARKING CITATION
cnu�on No.: 820900$26317
Cw No.:
St Paul Poace Departrnent
V�hieb lie�ns�Numb�r: 17HDCZ ec.c.:MN USA
V�hlel�VIN:
Mak�:TOYOTA Modd:NOT IN LIST Color:SILVER ,
Typ�:PA88VEH
TaD MoMh�1 T�b Y�v:12
Dat�o�Off�nu tON2/2012 Tlm�ofOR�n�e 21;13
Btatub/Ord Of/�n�s
168.OY.4 lXPIREDREGIlTRATION
Olfmu Locatlon:
EIfET'ER Pl Mt�n�etlnp 9tnK:M1881881PPI RIVER BIVD N
2nd Cro��Stn�t�
ORmu Cky:
Bt.P�ul
M�t�r Number: P�rmR Zon�: Siph�Wr.
ChNkin• CMIkOul: Pukad:(HN:MM) TIm�Zon�:
Unit:D!0
ofnwr�:PEO D.Lonpbehn,Jr
Ortic�r Numb�r:408505
Olfiqr9: ,
OTt�r Nump�r:
Report defective meten by noon the next business day
CaN(651)280�9776
To pay your flne by credk card,wak 3 buslness days and then call
�651)266�p202
N cited for No Proof of Insunnc�or No Drlv�n Llt�n��In Pos���Non,Proo!of Insuru�c�and/or
Drlwn Lk�n»should b�shown in on�of th�Vlolatlons 8un�u Loutlons IIK�d bNow wkhin
21 busln�st dayt Mth�Wolatlon.
To p�y your ckatlon oniln�: ��r��i pg .�fc urt�.stlR�.mm,y!
For�ddkiond iMonnallon or to pry your M�by td�phon�udnp�cndk card,
cw: �es�yzes�.
PI����h�v�your ekstian num6tr�nd endtt c�rd av�flabt�.
Mdl _ _- - - -- ___._..--.—.
P�ym�nts to: R�ms�y Dl�triet Court
rrune Vlolu�on�Bunw
76 Wat K�Ilopp Boul�vvd-Room 130
St.Pwl,MN 66104-7819
M�k�ehsek�p�yabl�to: Runay DlrtAct Court
(A eh�rp�of up to q0.00 wNl b�mnud on dl ntum�d ch�ak�)
Vlaldlons Bunau Loe�tbn�
8t.PaW Court Suburban Court L�vr EMorc�m�nt C�rR�r
___- _ 16 W.K�II�O pB�lvtl.RM 190 Z060 Whk�Y�v Ar�, 116 Orow Ytn�t
- St.T+wl,MN 66103 - Mapinrood,14�i6610i $f:F�,TilfJbb101
Oflle�Houre:8:00 A.M.-�:�0 P.M. Atond�y-FrICry(Exeludinp Holid�y�)
Fi�Wnq Ofllc�rs:8Y�PPoIMm�rit ony-eatl�661),Z86i102
Paymertt anA PenaRlet
Ityou wlah to pind puiky lor th�of'hnq(�)on th�nwru dd�of th�ck�tlon,you must do so
wlthin 27 dqt/rom th�dat�!h�cN�tlon b fll�d with th1 Cowt.lt I�your n�po�dbllity to
prqent your p�ym�M n�tlm�y m�nmr.Pbu�dlow 6 budrnn days for proe�ninp.A:6.00
I�t�/��is�dtl�d to NI unpud M�bU�nc��.AR�r�0 d�ys/rom th�d�b!h�cHatlon I�Ill�d wllh
th�Court�ddklond d�8nquene�u�may b��dtNd to dl unpdd M»�mourrt�.
Addftlon�p�naltlu m�y includr t)r�hml to th�Dop�rtm�nt of Pubtlo Sd�ty for drlvsPs
Iieen���utp�mion,2)�rn�!wvru�t bsu�d,�ndtor 3►nbrnl to�eoll�cllonr apmry.
Hth�oll�n��la�p�tty mlad�m�anor,hilun to�pp�v wlll b�eondd�nd a pi�a of pulfty and
walv�r to th�rlaM to trlal unksr ths hllur�to�pp�v h dw to elreum�t�nd�b�yond th�
p�non'�coMrol�M.B.1Q9.�1�.
Appeal
7o pbed not yWky,or to pl�atl puHty and olhr m�rplamtion:
1)11R�r 9 bwinus d�,e�l�Q61,Z66-0102 to eoMlrm th�t th�cit�tlon hu b��n Al�d
with th�court.
4)Mth�ck�t�on ha�bun 111�d,rpwN�h�vinp oMc�r�ppotrrcm�M.
3)Wh�n you arrive at tt»Vbl�tiotu 8unw,t�U th�c�thl�r th�t you h�v�a h�Yind
N11c�r�ppoiMm�nt.You must Yur�a photolD wilh you.
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