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Roberts ��.M�i��a��'��..,' ���������� - , Jp,N ,� 4 Z013 NOTICE OF CL��4�Vf��($�I to the City of Saint Paul, M��p , at� �:� r �{. e „� q:. Minnesota State Statute 466.03 states tha�';�;�.e�{ery�i��if:�.who claims damages from any municipaltty..shall caus�('o�e,�e�e��the governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating t�'e��me,plac , 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 pag�s 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 M�ri a� Middle Initial L Last Name f�obe,r�-s Company or Business Name, if applicable StrQat �.lrirlrecc ���l0 T�/1nYr�G.S �evt City ��. t�i,u,1 State �llv Zip Code ��/O�/ Daytime Telephone ( �►_) �3H-q'8545 Evening Telephone ( ) Date of Accident/Injury or Date Discovered i a�I 0�ia - Time�o �0 �m/pm (circle) Please state,in detail, what occurred, and why you are submitting a claim. Please indicate why or how you fee the City of Saint Paul or its employees are involved and/or responsible. wr a rr,� �ia i� �a . ' � �S Gt S " - '� 11.Q.+� !� w� � .� G�,s� �� Ec.. — ✓ I —r � '�� ,`� � a- f i� a�,.v �u.�e ?�..�b Please check the box(es) that most closely represent the reason for comp ting t'his form: � ❑ Vehicle was damaged in an accident O Vehicle was damaged during a tow ❑ Vehicle was damaged by a pothole or condition of the street � ❑ Vehicle was damaged by a plow �.:��:iiiCiE rd'.'.:i wr:,��g;jally toix��u a:iC��vT�1GK�ica't z7 L7jure�i c3�r��7'Fr�oper[y' _�'_______`_,.�—�-._ ❑ Other type of property damage—please specify O Other type of injury—please specify ❑ Other type not 1'rsted—please specify In order to process your claim vou need to include gonies of all applicable 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 Notice of Claim Form, City of Saint Paul, page two All Claims-nlease complete this section Were there witnesses to the incident? es No Unknown (circle) If yes, please provide their names, addresses and telephone numbers: <_ ��S5�Ca �o Ir,--t�" f-� J� � T trt�v�,��� �2. �o�� — 3� �� U � �v � 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>� � ��1��� �-Tvfu.� C��r-�LC,s �-�,.�-, i��v� a,- ��{-� Vehicle Claims-please comnlete this section �ck�eck box if this section does not apply Your Vehicle: Year i�.V V- 1 Make�or� Model �c,�.g� License Plate Number 57�ln - l-�7_tt State�_Color ��v Registered Owner Il/�w►-�n. �tG,P.v f3 Driver of Vehicle ,r�'�-- b�� f3 Area Damaged 1�� [�.ct,v�-�.A _ fv \/?.�►.+��1.-� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Injurv Claims-please comnlete this section �check box if this section does not annlv How were you injured? What part(s) of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment (circle) wnen ctid 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 thu for►n,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms may not be processed. Submitting a fa[se claim can result in prosecution. Print the Name of the Person who Completed this Form: � �C�v��t �t���e r `�C 5ignature of Person Making the Claim: `'l�f��t� �� Date form was completed�T /�.f�lo�� Revised Apri12006 1 Page 1 of 1 � Saint Paui Poiice Impound lot, 830 Barge Channel Road, Vehicie Release Form M�ke:09 FORD �icense#: 576HZY CN: 1225$997 invoice#: 1781g Date/Time Reisas�d 12�10�2012 07:03 Tow Charge: $ 123.95 Reieased to TOTO Storage Charge: S 0.00 Pa�r� by CREDiT CARO Admin Charge: S 80.00 ReleasPti hy EUSE Tax:(7.625°/a) � 15-55 l.tr7e unders�ned,have recovered Ihe vehicle described abave. Subtolal: $ 219.50 !w+il check tne vehrcle for dam�ge or any other problems that niay have occurred wh�ie this vehicle was m the cusiody of the Serv�ce Charge: $ 0,00 Sa�nt Pau� Pohce Department I acknowiedge I will report damage andlor an�r pth�r prabiems to the impound Lot siaff Total Charges: 5 219.50 on lh�s iprr� pnar ta leav�ng fhe impound tof Damage andior other prob(em __ Polroe Report made' Yes�No_iF Yes, CN , If NO.Why? TO PROTECT YDUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT S�gnature , �� � https://docs.google.com/viewer?attid=0.1&pid=gmail&thid=13b974633ab 188ee&url=htt... 12/15/2012 .l 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. Piease respond to these questions: Strongly Agree Disagree Strongly Agree Disagree 1.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 ] 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 familv relative ❑ Friends ❑ Occupational career guide book/magazine ❑ Other io Page 1 of 1 _ . - �_, ,.. : �: ���,����k.d,:: � � ; ;� � � �� � '�� � `il STA�T�tIF il�'�.��'A�'f iaOUf� �r u�,� � - ��� , q , � . .. _ �. , . , � �,. .�.�, __ � � ,u.. �. -_r �.'��±�oa_ �!,__ . , �_ -,'`�`����:� � ` , �,,„ A a ��� ^� � � �� ,� � '�'�'�. � Y �'F,1��� � -'k M ��5 � £M:. � AS �y, . #3r ,'f� . _ �� y _�.� ��� �� ��� � k � � � � �� �� �---��.w.��_� i�:� �,,;► �. ¢ <�s: ; 4 � �....�....��:' � ��: .a�� ��,� '? «� ��.� r; � _� _ z,� ���.�Y�..` V �."�` �' �5 � ���'"x�� � �II.�..,..� �'����.���l3�t'� �" � � {� �;�,� ' � ;�; z.. .� � � � �� w : . ` � ` , � ,,. �-. y � � -t ' 4 t,Y � � ��a� �" � 3 � . ,: .. «: w', .� s� '�- F t � . _ .. S * _. ., �"'—'--- �--=i..,.�+'rrewirr-i.�+..ir� � - ��. ����. � �� _ � � +i. . if � 'M '�"'�'�' i`.�.. � ., ,. � V t, �� � art ;t 4�%r i . , „ . . .. x .,.- t.� : .w._ .�+ �� _� �,�, .,. . _ ; - - b'�� - - '";1. 4 �. ¢• � � �"Y .Nn J�E' , :�F r,�" •:1 �. i . ,�: , .: �. .. - ` £ 3 s .. - „� ' . � � .3� ,� ` � t �LM . �e f� ��� _ x '. ..: _ "t 3E�. yYZ .�5; � �� d_-� N d'S ..¢.�S�' - .`�`'3'. > Ave. � 3X+`deF _ _ _ ��^. � z x�`y.",��s,�. `"'�w- _ , . .. : .. _. : �_ ... . _.. ..:__- . : ,.., �� �� .. .. ,. . .. .����� https://docs.google.com/viewer?attid=0.1&pid=gmail&thid=13b974633ab 188ee&url=htt... 12/15/2012 6 a�pa�n�oux3o Inap ina.r8 d•� �a�painnoux3o jnap poo8d•Q 'a�paimoux3o zunoaun a8v.rann ttd •� •a�pa�nnoux a�u?I tj 'g •a�paimoux�Sue�'jp.rnH•d •uot;�dn��o���p ut anet��q�nu asn�n3 aqi�aam�.zom pu��iep�utx.con�3o uos 3eqM'OZ •a�pa�nnoux3o Inap 7na.�S d•g •a3pain�oux3o lnap poo8 d•Q ' 'a�p;�lmoux38 tunotun ariv.�ann a�;•;} •a�painnotn�ai�ltt d'g •a�painnocni�Cue�fjp.rnH•d •uot3edn000 io qof3o putx3o puni��q�ut�ui�uenp�3o sa�ueqo aqZ'6I •a�pain�oux3o 1vap�na.r�d•g • •a3pain�oux3o pnap poo8d•Q II •a� a n�o o unouin aSn.rann P I �i3 J u`d'� i •a�painnoux aillit�''g � �a�pajn�oux,Cue�'1p�nH•d �uoi�edn��o 3��oaa►�ut��a��o s,C�nn�ua.�a�iQ•g i •aSpainnoux3o tnap�na.�8 d•g •a�pa�nnoux3o lnap poo8 d•Q •aSpainnoux3o�unown a8n.cann ud�� •a�pa�MOUx aI�3T[�''g •aSpainnoux�Cu��fjp.�nH•y •am�n3 a�ui qof3o putx lEyi uo a�doad io3 paau aq1,�LI •a�painnoux3o rnap lna.r8�•� •a�pa�moux3o lnap poo8 d•Q �aSpaienoux3o 1unou�n a8n.rann ud•� •a�painnocni a�laii d'g •aSpainnoux�iu��fjpavH•d •uo�;sdno�o3o putx iec�io3;saq a.����pa.ta�o sas.�no�aqZ'9I �� �z�3 � � z- This claim form is being returned without having been set up as a claim for the following reasons: Failure to provide a written description as to what happened and why a claim form was being submitted (page one). Failure to provide the proper and required documentation (page one). Failure to provide a date of accident or injury(page one). Failure to indicate the amount of dompensation being sought (page two). � Failure to provide information about the vehicle involved (page two). � `�� � � �?,G�.�7�' �aJO GyC�.�T Failure to provide ini rmatio7i about the injury claimed(page two). �Failure to sign the ctaim form (pa�e two). �� v�,� � ��3�I��- '"�'� 5 �� �Failure to print the name of the person who completed the claim form (page two). _ � � �jN'� '2� 1� � � Other: �' � ��� / vc.c� ����t�tt �y�,�� �v'� - yt,(�— Please return the completed claim form to: Office of the City Clerk City of Saint Paul 15 W. Kellogg Blvd. ' 310 City Hall � Saint Paul, MN 55102 If you do not return the completed claim form with the appropriate documentation or information completed, then a claim file will NOT be established and an investigation WILL NOT be done. Ir� other words,NO FURTHER ACTIGN will be taken until the information requested is provided by you. Please remember that it is a crime to submit a claim form or to pursue compensation falsely or under false circumstances.