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DEC 2 � 20iz
NOTICE OF CLAIM FORM to the City of Saint���u�;&�i�i�nesota
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 ihe alleged loss or injury is discovered a notice stating the time,place,and
circumstareces thereof,and the amount of compensation or other relief demanded."
Piease complete this form in its entirety by ctearly typing or printing your answer to each question. �f more space is
needed,attach additional sheets. Please note that you will not be contacted by telep6one to clarify answers,so pmvide as
much information as necessary to e�lain your claim,and the amount of compensation being reque.sted. You will receive a
written acl�owledgement 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. ff something dces 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
i " l i �A�� Middle Initial U Last Name �^ O V �--
First Name -
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address i � �� I h t� i'�'t af AV L
City 5�. �a"�� State M `v Zip Code����
Daytime Phone(95�)�I3- �t 7a Cell Phone(���f t3-S[?v Eveni.ng Telephone(��J9(3 -5��17�
Date of Accidend Injury or Date Discovered � Z �� r� Time / ���' /pm
Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how you
feel the Ci of Saint Paul or its employees aze involved and/or responsible for your damages.
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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
❑ My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
J�My vehicle was wrongfully towed and/or ticketed _ �I was injured on City property
❑Other type of property damage—glease specify
❑ Other type of injury—please specify
In order to process your claim vou need to include rnaies of all aaalicable 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 estunates 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
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 retumed.
Page 1 of 2—Please complete and return both pages of Claim Form
C
Failure to complete and return both pages will resWt in delay in the handling of your claim.
All Claims—nlease comvlete this section
Were there witnesses to the incident? Yes No Unkno (circle)
Provide their names,addresses and telephone numbers:
Were the golice or law enforcement called? � No Unknown (circle)
If yes,what department or agency? ����`C� Case#or report# l Z2�3� 9�7
Where did the accident or injury take place? Provide street address,cross street,intersection,name of pazk or f ty,
closest landmark,etc. Please be as detailed as possible. ff necessary,attach a diagram. Cat� �.res S �ec
n Da�nl �,�� �e�� �c9.rnti ,c� -
Please indicate the amount you aze seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ���? �U
Velucle Claims— lease com lete this on ❑check box if this section dces not a 1
Your Vehicle: Year Z�° l Make 1��nc�4 Model �c i
License Plate Number 2 ' J�-I y Statc�'i l� Color I° c'_
Registered Owner M�`� ����
Driver of Vehicle N A
Area Damaged �""
Ciry Vehicle: Year Make Model
�k License Plate Number State Color
Dnver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims ulease comnlete this section �check box if this section dces not auvlv
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
�,Check here if you are attaclung more pages to this claim form. Nwnber of additional pages 2 •
By signing this form,you are statiing that all information you have provided is irue and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submilling a false claim can result in prosecution. Date form was completed ����'2'.�f Z—
Print the Name of the Person who Completed ttus F rm: � I,C YL a�I � �O V{—
Si ature of Person Mal�ng the Claims ��""�
�
Revised February 2011
Saint Paul Police Impound �ot, 830 Barge Channel Road, Vehicie Release Form
Make:07 HONDA License#: 225JHX CN: 12288997 invoice#: 17832
Date/Time Released: 12/10/2012 07:36 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 8U.00
Released by: ELISE Tax: (7.625%) $ 15.55
I
I,the undersigned,have recovered the vehicie described above. Subtotal: $ 219.50 �
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: $ 219.50
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
Signature �2000
_-_�_._.... .__. -- -
sr rt�u. I�T�
SR LBNT�PAUL. Itl. 551�7-2450
651-266-E�692
Ifercheot ID: 86�1G3S0144
Ter■ID: 00173400(iV�b�94�
Sale
�� EntrY Nethod: S�i�ed
VISR
Total; $ �9.58
� 12i18�12 0Z;36:36
I�q; �166814 I�ur Code: �88163
i�arud: Online
CusYomer Covv
,^___ _._ _ _ �
� . Citation# 8 8 8 .s�7�
ST. PAUL
STATE OF MINNESOTA-RAMSEY DISTRICT COURT IIIII)I`III IIIII IIIII IIIII IIIII IIIII IIIII(1111I�II IIII
es and sa s: I
The undersigned,being duly sworn,Upon his/her oath depos Y * g g g 7 4 9 2 7 1 *
Date of Offense / � Time of Offense '
Plate
Veh.License No. Year State Make Style Color
Location of Offense:
VIOLATION: - f SNOW EMERGENCY St. Paul Ordinance 161.03 FINE $53.��
(Amount includes mandatory state surcharges of$13.00)
CN
Citing Officer Citing
Officer Number Dept.
❑Posted Night Plow � ay ow �-- -OPaewed in1lLVindrow�` CtTagged Before Plow ❑Drove Off
OFFICER'S NOTES
❑NO PLATE VIN:
Citation can be paid at the Impound Lot.Please read the back of the citation for payment instructions.
CITATION
• To pay your citation online: 2�idweb�:ay.courts.state.mn.us
• For additional information or to pay yuur fine by telephone using a credit card,call: 651-266-9202 ,
Please have your citation number and credit card available.
• Mail payments to: Ramsey District Court Make Checks payable to: Rarpsey District Court
Traffic Violations Bureau (A charge of up to$30.00 will be assessed on all returned checks)
15 West Kellogg Boulevard-Room 130
St. Paul, MN 55102-1613
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Violations Bureau Locations
St. Paul Court Suburban Court Law Enforcement Center
15 W. Kellogg Blvd., Rm 130 2050 White Bear Avenue 425 Grove Street
St. Paul, MN 55102 Maplewood, MN 55109 St. Paul, MN 55101
Office Hours:8:00 AM-�:30 PM Monday-Friday(Excluding Holidays)
Hearing Officers-By appointment only. Call(651-266-9202)
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Payn�ent and Penalties
If you wish to plead guiity and submit payment for the otfense on the reverse side of the citation,you must do so within 21 days from the date the citation
is filed with the Court. It is your responsibility to present your payment in a timely manner. Please allow 5 business days for processing.A$5.00 late fee
is added to all unpaid fine balances.After 40 days from the date the citation is filed with the Court,an additional delinquent fee may be added to all unpaid
fine amounts and the case may be referred to a collections ager,ry. If the offense is a petty misdemeanor,failure to appear will be considered a plea of
guilty and waiver of the right to trial unless the failure to appear is due to circumstances beyond the person's control(M.S. 169.91)and(M.S.609.491).
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Appeal
To plead not guilty,or to plead guilty and offer an explanation,take the following steps: 1)After 10 business days,call 651-266-920�to confirm
that the citation has been filed with.�he-6ourt,and 2J request a hearing officer appointment.You must have a photo ID with you when meeting
with a Hearing Officer.
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I understand that by�ayina this fine I am entering a plea of guilty to this offense and voluntarily waive the following rights to:
1. The right to a trial by the Court in which I am pres;amed innocent until proven guilty beyond a reasonable doubt.
2. The right to confront and cross-examine all witnesses against me.
3. The right to remain silent or to testify on my own behaff.
4. The right to subpoena and present witnesses to testify on my behalf.
I also understand that this offense is a petty misdemeanor and the maximum penalty is a$300.00 fine.