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Roberts ��`�� NOTICE OF CL��C$�I to the City of Saint Paul, M��p , Minnesota State Statute 466.03 states tha�'`�.�.e�fe►y��f4,who claims damages from any municipality...shall caus�'o�e,�e�er��the governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating t�ie�ime,plac�'d� 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 may or may not be contacted by telephone to discuss your claim circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. This form must be signed,and both pages com�leted. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,290 CITY HALL,SAINT PAUL,MN 55102 First Name Mar►c� Middle Initial �.., Last Name f�obe�rts Company or Business Name, if applicable Street Ad�ress _ �o�a� Tl�ovr�,..s �,c City��. �.1 State ��/IIV Zip Code ��/Oy Daytime Telephone"(�) 33H-q'85`d Evening Telephone ( ) Date of Accidend Injury or Date Discovered i 3�i��ia Time�a"�� m/pm(circle) Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or how you feel the City of Sai t Paul or its employees are involved and/or responsible. 0.!r r v�� /�, /c� I a, . ` e -e . fS a �� 1 �� V w� � � n G� i� �c. — v 1 T l�'L c� l� �' a- f--�/o�,.� �u,�e "7'•-t s . Please check the box(es)that most closely represent the reason for comp ting this form: ❑ Vehicle was damaged in an accident � Vehicle was damaged during a tow ❑ Vehicle was damaged by a pothole or condition of the street � � Vehicle was damaged by a plow �.�Jehicle•�vas wrongfullyto�ued and/ar�icketed ❑ InJured�n Cit-�property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify ❑ Other type not 1'rsted—please specify In order to process your claim vou need to include conies of all auplica6le documents. This is a general guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to provide additional information depending on your claim. O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle,or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts O Other property damage: repair estimates,detailed.list of damaged items O Injury claims: medical bills,receipts O Photographs can be provided but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form � j Notice of Claim Form, City of Saint Paul, page two All Claims—please comulete this section Were there witnesses to the incident? es No Unknown (circle) If yes, please provide their names, addresses and telephone numbers: �_ 1�S5� Cc. �o Ir,-rX t� �� T�t�vn.cj�}'V 2. �� - 3� � t �V w Were the police or law enforcement called? Yes Unknown (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 helpful, attach a diagram. Please indicate the amount you are seeking in compensati from this claim or what you would like the City to do to resolve this claim to your satisfaction:� � �°r;�� ' .� C ,S �-�,-,-�, i - �� - ��}-� Vehicle Claims—please complete this section �ck�eck box if this section does not applv Your Vehicle: Year OO�I Make -�or-e.f Model �=z�c,t eS License Plate Number 5��- f-�7_� State�_Color �v Registered Owner AJIw►-�n- i2�t��f3 Driver of Vehicle .r�►`�- b�i✓ i3 Area Damaged � [��vK-�.GI� �v V�.1�►,+��L�- _ City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniurv Claims—nlease complete this section �check box if this section does not apnlv 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 attaching more pages to this claim form. Number of additional pages By signing this form,you are stating that aA information you have provided is true and correct to the best of your knowledge. Unsigned forms may not be processed. Submitting a false claim can result in prosecution. Print the Name of the Person who Completed this Form: Signature of Person Making the Claim: Date form was completed Revised April 2006 Page 1 of 1 � Saint Paul Police Impound lot, 830 Barge Channel Road, vehicie Release Form Make: 09 FORD Lirense#: 576HZY CN: 12288997 invoice#: 17819 DatelTime Re�eased� 12�10/2012 07:03 Tow Charge; $ 123.95 Released ro TOTO Storage Charge: S 0.00 P,��d by CRE�IT CARD Admin Charge: S 80,00 Reieasr�ci hy EUSE Tax: (T.625%) $ 15.55 I,the unders�ned,have recovered the vehicle described above. Subtotal: $ 219.50 1 w.►I check the veh�de for damage or any other problems that niay have occurred whde th�s vehicle was m the custody of the Servfce Charge: $ 0.00 Sa�n� Paul Police Departrnent 1 acknowiedge I will report damage and'or any other problems to the Impound Lot staff Total Charges: $ 219.50 on ih�s fo�r� pnor to leav�ng the impound lot Damage and�or other prob�em ___ Polrc�e Report made� Yes^ No_IF Yes, CN , If NO,Why?_ TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE IEAVING THE�T - - -- an000 S�gnature� _ - https://docs.google.com/viewer?attid=0.1&pid=gmail&thid=13b974633 ab 188ee&url=htt... 12/15/2012 Part IV: Career outcome expectations: Read each statement below and indicate your level of agreement to the statement. Circle only one response for each statement. Please respond to these questions: Strongly Agree Disagree Strongly Agree Disagree l.My career planning will lead to a satisfying career for me. 4 3 2 1 2.I will be successful in my chosen career/occupation. 4 3 2 1 3.The future looks bright for me. 4 3 2 1 4. My talents and skills will be used in my career/occupation. 4 3 2 1 5.I have control over my career decisions. 4 3 2 1 6. I can make my future a happy one. 4 3 2 1 7. Who influenced your decision the most to choose your current career path or career program? (check only one) � High school counselor � A high school teacher ❑ Mother/Female guardian ❑ Father/male guardian � Brother/sister � Close family relative ❑ Friends ❑ Occupational career guide book/magazine ❑ Other 10 Page 1 of 1 . � , � - �v.. �� . � ��` y�.� � ��t��r�t�►��y�r�r cxw+rr .. �r„��wr s� _ - - . ° , �� - x �� '+w�.r.��[If� � -� ,_ �-' ��-h�r�. :.��. `^��"-,��t t �� . �' � : �.` ; 1�,�� .. � ��+�r------,.-�--�—� `� i l�tit�: .,.�` u� ,��:. 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