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NOTICE OF CLAIM FORM to the City of S� �'a�.�;�iinnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any mirtticipality..'.shall cause to be presented to the
governing body of the municipaliry 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 other relief demanded."
Piease complete this form in its entirety by ciearly 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 exptain 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, SAINT PAUL, MN 55102
First Name A"�'eW Middle Initial T• Last Name �e��
Company or Business Name NA
Are You an Insurance Company? Yes No If Yes,Claim Number? NA
Street Address 2338 Marshall Avenue�207
City st.Pa°i State � Zip Code 55104
Daytime Phone( NA - Cell Phone( �63 ) 2so _ sa�s Evening Telephone( NA -
Date of Accident/Injury or Date Discovered January 14,2013 Time 9�14 /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 Paul or its employees are involved and/or responsible for your damages. '
On Januar�2nd,2013,si�rts went up along Otis Avenue prohibiting parking for the month of January to allow space for a construction �
project.Over the weekend of January 12th,however,all said signs were removed.I parked my automobile along Otis Avenue on
Sunday,January 13,2013,at approximately 12:OOpm,double checkfng that no parking restrictions were posted.The next morning,
January 14,I discovered the signs had been reposted;My automobile was ticketed and being towed.At the scene,I had to pay a$75
(cash only)drop charge to the towing operator to release my car.I was not given or offered a receipt.SPPD Officer Ayers(No.27510)
was at the scene and witnessed the transaction.The building permit posted at the construction site states all parking restrictions must
be posted wit -hour notice. successfu ly appealed my park ng ticket wit the County of Ramsey District ouM.
Please check the box(es)that most closely represent th�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
�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 vou need to include conies of all analicable 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 WILL NOT be returned and become the property of the City. You aze 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; or the actual b' ' t for the re airs
(Car was not
O Towin claims: le 'bte co ies of an ticket issued and a copy of the im ound lot taken to
O Other property damage claims: two repau�est�ma s i e ge exceeds $500.00;or the actual bills ;mpouna�ot;
and/or receipts for the repairs;detailed list of damaged items drop charge
O Injury claims: medical bills,receipts was paia at
O Photographs are always welcome to document and support your claim but will not be returned. the scene.rro
reciept was
Page 1 of 2—Please complete and return both pages of Claim Form given)
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease comulete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police ar law enforcement called? Yes No Unknown (circle)
If yeS, what department or agency? St.Paul Police partment Case#ar report# Incident 2508875/(�tation 62090057028f
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 necessary, attach a diagram. 216 Otis Avenue
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to y0ui SahSfaChOri. R�eimburse my$75 dollar drop charge
Vehicle Claims please comnlete this section ❑check box if this section does not avvlv
Your Vehicle: Year 1995 Make Volkswagen Model Golf
License Plate Number 388 FWP State IA Color Btack
Registered Owner .�narew octeaa�
Driver of Vehicle NA
Area Damaged NA
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims nlease comnlete this section �!.`check box if this secrion does not anplv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss wark as a result of your injury? Yes No
— When d"id you miss wo? -- - - - - --- -- (prev�de date(s)}
Name of your Employer:
Address Telephone
�Check here if you are attaching more pages to this claim form. Number af additional pages 2
By signing this forna,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned for�ns will not be processed.
Submitting a false claim can result in prosecution. Date form was completed February S,2013
Print the Name of the Person who Completed this Form: A N��E`�`� d F'��'L
Signature of Person Making the Claim: ���'�'�`
Revised February 2011
3tate of Minnesota • Ramaey District Court
CITY OF SAINT PAUL
PARKING CITATION
crtu�on No.: 620900570288
Cu�No.:
8L Paul Potice Department
Whlel�Uc�ns�Numb�r. 3BSFWP 8tatr�1 V.Sl4
V�hicl�VIN:
M�N�:YOLKSWAGEN Mod�l:NOT tN LI3T Color:BIACK
Typ�:PAS$VEH
Tab Month: Teb Year:
Dat�otOlfsros 1h41Y013 TlmsotolNnes 0�:14
BtNUl�lOrd OR�nu
169.34.1(a►(14�PARK YYNlRE 810N8 PRONIdIT --"�� __
Off�nss Locatlon: ���.
216 OTIS AV Int�n�ctlnp Stn�t:MARSHALL AV
2ntl Croe�StrsM:
OR�n��Clty:
Bt,P�ul
MNSr Numb�r� Psrmk Zone: Slqne Vls:
ChaIN ln: Chdk 0ut: Parlwd INH:MM► Tlms Zon�:
unit:96Z ,.
Ofne�r i:PEO L.Ayen
OIfIC�rNumb�r: Z7570
Ofllc�r Z: .
Olfic�r Numbsr
Report defecdve meters by noon the nezt business day
Call(e51)26e-9776
To pay your flne by credR card,walt 3 business days and then call
(651)266�9202
If cltsd for No Proof otl�surance or No Driv�rs Lle�n�e in Posa�sdon,Prootof Insuruic��ndlor
Driwn Lk�m��hould bs�how�In orn otth�Vlol�tlons Bunw locadons Ibt�d bdow wkhin
21 busineta d�ys of th�vlolNion. �
Topayyourek�tlononlin�: www.2ndw�bp�.courts.tt�t�.mn_.us
For addkionai In/ormatlon or to p�y your Rns bytsl�phons usinp�crsdit card,
GII: (661)266-027t.
Pl��s�hav�your eftallon numb�r�nd endk evd avdl�bl�.
Mdl p�ym�Mt to: aams�y DlsMet Caurt
TraRfe VleNtlorn Bunaii
- 16 W�rt K�Ibpp BouNr�rd-Room 1J0
St.Paul,MN 66102•1819
MaMs ah�eMs p�yabN to: Runs�y DlsMct Court
(A ch�rp�ol up to q0.00 wlil b�uuu�d on dl rotum�d ch�ck�)
� Vlolatlon�Bunw Locatloro � �
8t.Paul Court Suburb�n Court Law EnforesmsM Centsr
16 W.KsUOqp 81vd.RM t90 4060 Whk�B�v Aw. 146 Grov�Btn�t
St.P�ul,MN 66102 M�pl�wood,MN 66109 St.Pwl,MN 66101
Ofiu Houn:8�00 A.M.-1:30 P.M. Mond�y-Friday(Excludinp Holid�y�)
H�erinp O111c�ro:6y�ppointmsnt ony-edl(Q61)-268-0202
Paymsnt antl Penaltles
fl you wfsh to pind yufky tor the olfenu(f J on th�rw�n�Nd�ot th�ck�tlon,you must do to
wkhin 21 daye Irom th�dats th�ckatfon Ie fll�d wkh th�CouR.ft li your nspondbllfty to
pn�mt your p�ym�nt n�timsly mannsc Pbu�dlow 6 busin��s dys for procosinp.A i6.00
I�U f��Ia add�d to�II unpafd Ms bdanc��.AR�r 10 days hom th�dN�th�cR�tlon h fll�d with
th�Court addkional ddfnqusM fs�s may b��dd�d to dl unpdd M��mounts.
Additiond penattlss may Include:1)retsirv to thr D�partmsnt of Publlc Sd�ty for drivsr's
Uunse ausp�nsfon,2)err�st wsrnnt h�usd,and/or�)nhrrd to a eollsetb�t ap�ney.
It th�oR�ns�ia a p�tty ml�d�m�anor,ftlWn to�pp�v will b�eonsid�nd a pl��of pulRy ind
waiver to ths riyM to trial unl�ee ths tdlun to�pp�ar I�dw to circumstanut b�yo�d th�
p�non'�control(M.8.1N.�1).
Appeai
To plsed not puitty,or to pls�d pulky�ntl off�r�n�xplanatlon:
1�ARer J business d�ys,eall6d1-266-0202 to eonflrm that ths ckatlon has b��n fllsd
with th�court.
2)M the ekation hat been fflsd,nqu»t a h�viny olflesr appolMmsnt.
I���I���qIII��I�II�I�II���II�IIIN�I�II+II��I�II INCIDENT INFORMATION REPORT 2ni2o�3f 1
STATE OF MINNESOTA
' COUNTY OF RAMSEY
DISTRICT COURT
INCIDENT AND CITATION INFORMATION
INCIDENT ID PAYMENT PLAN CITATION NUMBER
2508875 620900570288
DEFENDANT NAMEANDREW THOMAS OFTEDAL
ADDRESS 2611 NORTHWOOD DR
AMES IA 50tl10
DEFENDANT INFORMATION
DATE OF BIRTH 7/5/1940 GENDER MALE
HEIGHT 5 Feet 8 Inches EYE COLOR BLUE
WEIGHT DL NUMBER 299W5286 DL STATE IA
RACE WHITE � HISPANIC (Y/N)
OFFENSE INFORMATION
DATE/TIME 01/14/2013 09:14 DIVISION RAMSEY COUNTY
LOCATION 216 OTIS AV AND MARSHALL COMMUNITY ST PAUL
AV AGENCY ST. PAUL POLICE DEPARTMENT
METER ISSUItdG METHOD LEFTAT SCENE
OFFICER 1 27510 CN
OFFICER 2 NBRHOOD
VEHICLE INFORMATION
PLATE 388FWP MAKE VOLKSWAGEN
STATE IA MODEL
PLATE YEAR COLOR BLACK
VEH TYPE PASSENGER VEHICLE VIM
VEH YEAR
RESPONSIBLE PARTY ID METHOD
NONE
CHARGE INFORMATION STATUTE/
STATUS REASON JURISDICTION ORDINANCE DESCRIPTION
CLOSE FNSUS STATE OF 169.34.1.a.14 Stopping/standing/parking where signs prohibit
MINNESOTA stopping
ORIGINAL FEE INFORMATION AMOUNT DUE
$20 FINE 20.00 $20 FINE .00
Srchrg-2nd District 1.00 Srchrg-2nd District .00
Srchrg-Parking 2009 12.00 Srchrg-Parking 2009 .00
GRAND TOTAL 33.00 GRAND TOTAL .00
OFFICERS COMMENTS
NO PARK ZONE THIS SIDE OF STREET. 24 HOURS JANUARY 2-31ST