Xiong (3) r�C+.,r. � �., ,�s �
APR o 5 2013
NOTICE OF CLAIM FORM to the City o�Y�a�in�����1Vlinnesota
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 fhe�leged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amou 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 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, SAINT PAUL, MN 55102
, 4` ` .
First Name V Q� Middle Initial l� Last Name � �
Company or Business Name
Are You an Insurance Company? Yes� If Yes, Claim Number?
Street Address `��` �eal'��,(/� �lPi
City���1'1�[ �G(,(�( � State ��V Zip Code 5���
Daytime Phone (��-�Cell Phone((.QS))�-��Evening Telephone([es/)�I yZ-f 23�
Date of Accidentl Injury ar Date Discovered Lf Yj.,�� �2.�(� Time w f�� am/�
Please state,in detail,what occurred(happened),and wl�iy you are submitting a claim. Please indicate why or how you
feel the City of Saint aul or its employees are involved�nd/or responsible for your damages. .��.�G.� ���
(]('�'.1�� _� °�
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�'ehicle was damaged by a pothole or condition of the street ❑ My vehicle was dama.ged by a plow
L�1GIy 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 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 estihnates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills andlor receipts for the repairs
O 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 returned.
Page 1 of 2—Please complete�nd return both pages of Claim Form
Failure to complete and return both pages will result in de�ay in the handling of your claim.
� �
All Claims—nlease complete this section
Were there witnesses to the incident? � No . Unknown (circl
Provide their names, addresses and telephone numbers: ` —1 2-�J�
Were the police or law enforcement called? Yes No "� Unlrnown , ,,(circle)
If yes,what department or agency? Case#qr 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 necessary, attach a diagram. D `_r�(1 ;t A
����I�,MN �t�(� � � ,
Please indicate the am unt you re,se kin in c mpensation or w at you would like the�:City tp d o re olve this claim
t your satisfac 'on. �I/ ' � '{ �" � �
� � S' _
Vehicle Claims— l�ase com lete this sec 'on ❑ check box if this section does not a 1
Your Vehicle: Year b Make 11 n� Gt, Model ��X
License Plate Number "(�lil/ State Color
Registered Owner�, )PI O i.e�e X i�n c�
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section � check 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
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 all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �'�`f�/,�
� �
Print the Name of the Person who Completed this Form:� � � �Gi�„ �
r
Signature of Person Making the Claim: � �o ��.---
Revised February 2011
�rlv name is Ja�Lee Xion�; I would like to file a claim in re�ards of a citation I
�eesiuea on Januarv 29.2013 resarding my vehicle. I was cited for havin� my vehicle
parked by my�ara�e for more than 48 hours, having expired tabs, and as an unregistered
vehicle. The followins dav I also received an Abatement Order from the Denartment of
�a�etv and Tnsnections bivisions of Code En�orcement statin�that I was to �urchase nev�
�abs and to move my vehicte before February 1 l. Zal3. Af�ernoon Qn Ianuatv 31.2413 I
rea,Iized mv ve�icle was towed understandins that I had until Februarv 1 lth. 2013 to make
the�han�es re�ardin�tt�e At�atement Order I received. After makin�many calls
cdr�cernins mv vetucle bein�towed. I understood�hat mv vehicie was towed bv the oi�icer
who wrote me the citation and that the citv of Saint Paul mav tow a vehicle at anvtime.
The week nrior to this event I did transfer the titie over to mv name and nurcnas�
new ta�s�or mv venicle. I dori t understand whv. I was cited as obtaitune an unregistere�i
vehicle. but mavbe the recent t�tle transfer was still in orocess. I want to file this claim for
an reimnursement for tne towine tees naid to take my vehicle out of the Saint Paul Police
imnound Lot. Alon�with ttus cla,im 1 have attachea a coov oi the Abatement l�rder.
citation, and receint for the Saint Paul Police lmnound�ot
�i�Tou nave any questions, �iease contact me at (b5f}333-��=��. ���::�y:;�:.
llF.PARTME:Td7'OF'SAFE"1'Y AND INSPEG'1'IONS
S1a_v4 bir.tp,ner,l�da�xrger nj Co%ie Enk:r�emer!
__ _ . _.___ __ _.-- - —
37S J,v.'Isa:.St>eet.,Suits 12Q ta'�,�nur:n•551-206-8989
�+�f�,�� �-�� ���yni_�-'' Sairit Faul,.�1�'SJ107-18J6 'acs;mite. bJi IG6-1`JI y
CF.risdaphrr fi C.�?rrncfz, :Lfayor W2b:x_x'�o. rru�oi•;�si
__ __ . �. _ __ ,_ _
Yo�h•r.is ti:u koj hais lus Hmaah thiab knj tsi,to taub tsab ni�«�•r+o,hu ra�:tus ttihai,lus nta.�r�n
,� (651 j 2b6-8984. tiws yog pab dawh zwh.Si nP.r,C351ta UO t(Ad+lctOC,p0(f3V0!'113t11'dROS aI{Gi 1)"L66-
&989. No cosin.
:�3G _�_ _..
�T�ilUal'� 29���13
�}lOU�i �1011n
��i�1 l�_C3ri�y �Vt�
S�ilTlt ���ll� �� �JIU(�°����
���������� ��T���
R.l?: 1761 R�;ANF:Y .1VF
Fi l c �: 1�-1475��
I�c;ir 5ir oi�'Vladam:
The, Citv of S�int Palxl, l7epazlment of Safcty and Inspcctions l�as in�pected thc �i�t74�e referenccd
pmperty ot�Januar<< 29, 2013 and h��s cictermined that thc follc►wing dcficiencies cxisl iii
viol�:itii:�rr oftl�e �aint Pa�al Lf;�islative.Cod�' {sec f�join�te 1, below).
�, t;p�AC',E?.: Pr���ide rcflectaxized or �llurriinated �ara�;e numbers frc�nt and rear wY�erc
applicahlc. Ttie nucnbers must be a rninirriuz� c�f three (3} inches in hc;i�;ht and mtist he
cle�.+r(�T ��isihlc. f'rom the strec:t��r alley (ar salety reasc�ns.
�'c�u ar� k��ret�y° �ac�lified to correct these d�ficieneics in accoraaciee ��itra the appropriate c�ae,.
Th� E�_afercc;mer�t C)flicer ��rill re;insp�ct these premises an or��Itc�r February 11,2013, bY w�iich
date thc violatic�ns n�7ted �n�ist l�e ��,r.rected. Failure t�► carrect these defciencies mxt resnit in
tiie issuaz�ce of c�rimianat claarges'` anci/or a civil lawsuit, and possiblc abatemenvassessnnent by
fk��, (;'ity. A).l re��airs an� new installati��ns must k?e rnade in accordance 1��th the appropri�te
cc�d�s. Pcnuits r:�ay be obtaincci by calli��g fi51-2fif�-89i�9.
�'c�u irzav file an appc�� to this notic�by cc�x�t�etin� lhe City (:��rk's (�ffiee at 651�26�-$6R8. Any'
ap�eal rriust bc madc Xn writixi� witl�in 10 days of this nutice. (Y<�u must subrnit a copy of`this
Nc�tic;c: u•hen you appeal, and pa�� a lilang fee.) .
If you have any qixc:�tions �r request ac�ditional inforrniat�un, plcase contact mc. To arrange
an d�pointment or request an extensian of time ta complete repairs,you will need tcr spcak
directly to me at 651-�Gt►-1940. � -
Sinc�:rely,
Scott
$ad�e #330
C'nDE�.NFORCF.MEh°T OrrICFR
t:,.,.E_.,.,,...
January 29, 'LO 1:�
1 i fi 1 KEf�NEY A�'1::
�'a�e 2
` l o see the Le�is�ative Cc,de go to wu��v.stpaul. ov on the interz�et, click on "1)epartments",
then click on "Department o#�Safety and Inspections", scroll down the page for the "Codes".
�.'Iost C'orrection Notices derive from Chapter 34.
? Crinninal charges can bc brou�ht on the day thc violation is observed, but generally we ali��w
tirnc to CorrCCt unless this is a repeat violatioii.
SS
W"nRN(tiG ('ndr inspection and entorcemertt tr+ps cust Lhe taxpayers moncy. If the violations are not corrected within ltie time pr,rie�requircd
;n th�s notice,the city's costs in condueting a reinspa:tion afeer the due date for compliance wili be collected fiom the owner rather than bcing
paid hy the taxpaycrs of the city. If ar]ditional netv violations ave di�c:overed within the ncxt follow�ing 12 menths,the city's anls in cvnducting
;idditional inspecuons at thi.<.same loca[ion within such 12 months will be collectcd from the nwner rather than being paid by the taxpayers of the
crty �1ny such future cosu�ti�ill he r.nllected b}�assessment against the real property and are in aelAition to any ollter fines or atsessmenu which
mav bc levied aeamst��ou N�d your property.
c,n!i0100 6�10
r
CITY OF SAINT PAUL )anuary 29,2013
DEPARTMENT OF SAFETY AND INSPECTIONS
DIVISION OF CODE ENFORCEMENT
375 Jackson Street, Suite 220
Saint Paul, MN 55101-1806
� VEHICLE ABATEMENT ORDER
Shoua Xiong Occupant
1761 Reaney Ave 1761 REANEY
Saint Paul MN 5 5 1 06-4243 St Paul MN 55106-4243
As owner or person(s) responsible for 1761 REANEY AVE
YOU ARE HEREBY NOTIFIED THAT THE FOLLOWING VEHICLES ARE IN VIOLATION
OF THE SAINT PAUL LEGISLATIVE CODE, CHAPTERS 45, OR 163:
�/ehicle
#1 #2 #3
Make Honda
Color Silver
License MN TWN-991
Violation A-Lacks current license/tabs
D-Appears
undriveable/inoperative
Vehicle #4 #5 #6
Nlake
Color
License
V iolation
VIOLATION CODE: A-Lacks current license/tabs D-Appears undriveable/inoperative
B-Open to entry/unsecured E-Unimproved surface
C-Missing vital parts/dismantled F-Other violation
FAILURE TO COMPLY MAY RESULTS IN TAGGING AND/OR TOWING.
CHARGES: If the City impounds ana disposes of the�=ehicie�s), ��� �=�µrg�s R3�ES��u �a ��s ai�:.►�'�
property will be approximately $1,000.00 for each vehicle. This charge does not include impound fees
and other related costs for release of vehicle s .
Vehicles found to be in violation on or after February 11,2013 will be removed,impounded and disposed of in
accordance with law. The cost of this abatement will be charged against the property as a special assessment to be
collected in the same way as property taxes. Noncompliance with this order and repeat violations will result in the
issuance of criminal citation
Issued by: Scott Badge Number:330 Pho�:e Number: 651-266-1940
Appcals: You may appeal this order and obtain a hearing before the City Council by completing an appeal application with the City Clerk before the
appeal deadline noted above or seven(7)days after the date mailed,whichever comes first. No appeals may be filed after that date. You may obtain
an appeal applicalion from the City Clerk's Office,Room 310,City Hall,St.Paul,MN 55102. The telephone number is(651)266-8688. You must
submit a copy of this Vehicle Violation Notice with your appeal application.
*WARNING Code inspection and enforcement trips cost the taacpayers money. If multiple trips within a year to your property are required to insure
compliance with the law,you may be charged for the cost of inspections and enforcement trips to your property. Such charges are in addition to any
other fines or assessments which may be levied against you and your property. V�p2 60159 02/10
VrhiclrLicanseNumben TWN99� scea:MN USA
v.nioi.vw: 1 HGCB7158LA012889
Maks:HONDA Mod�l:ACCORD Color.GOLD �
Type:PASSVEH
Tab Month: Tab Year:90
Date of otFense 1129I2013 Tims o1 Ortanas 71:19
StatutsfOrd ORenas
189.34.7(a)(2) PARKISTOP BLOCKING DRIVENfAY
168A9.4 EXPIRED REGISTRATION
157.03.a.20 Park vehicle at same location more than 48 consecutive �
hours-
ORense Lowtion�
1761 REANEY AV Interesctlny Street:
znd cross stne!
ORenas Clty: .
"�eter Number Psrmit Zone�. Sipna Vis:
Chalh In Chalk Out: Parked: (HH.MM) Time Zone:
Unit:666
orticer t OfBcer Z.KOEGER
OffiurNumber 357200
ORIcer2: .
ORcer Number�. .
Report detective meters by noon the next business day
Call(651)268•9778
To pay your fine by credlt card,walt 3 busfness days and then call
(651)288-9202
If cited(or No Proo!of Insurance or No Drivsrs License in Posseenion,ProOf of Ineurance and/or
Drivers License should be shown in ons af the Violations Bureau Loca:ione listed below within
21 business tlays ofthe violation.
To pay your citation online: www 2ndwebe�_courts state mn_us
For additional inlormation or to p�y your fln�by telephone u�inQ a credit c�rd,
Call: (661)2685702. � �
Please have your citatlon number and credit card availabls.
Mell paymants to: Ramasy Dlatrlct Court
TraMlc Vlolatlons Bureau
16 W�tt KNloyp Boulovard-Room 130
St.Paul,MN 66102-1619
MaMe checMa payable to� Ramsey�istrict CouR
(A charpe o!up to 530.00 wlll b�nwss�d ca all ntumed ch�cke)
Violations Bureau Locatior¢
St.Paul CouR Suburban Court Law Enforcement Center
. 16 W.Kellopp 81vtl.RM 130 2060 Whlb Bear Aw. 426 Grovo Stn�t
St.Peul,MN 66102 Maplewootl,MN 66109 St.Paul,MN 66101 �
ORcs Houn:8:00 A.M.-4:30 P.M. Mond�y-Friday(Ezcludinp Holidayo) -
Hearinq ORicsra�By appointmant only-call�661)-266�202
Payment and Penaltles '
If you wish to plead flullty for th�oRense(e)on the reverse elde ef the citatlon,you must do eo
within 21 days from the date the cltatlon Is filed with the Court.It ie your responsibility ta
preeent your payment n a timely manner.Please dlow 6 buslnsas days(or proceealnp.A 56.00
late!ee Is added to all unpaid Bne balancee.ARer 40 days lrom ths date the citation is Nled with
the Court additlonel delinquent f�es may b��dd�d to all unpsid flne amounts.
Additional penalties may include:1)referral to ths Department of Public Safety for driver's
Ilcense auspenalon,2)errost warrant laausd,and/or 3)rd�rrel to a collectione ap�ncy.
I(the oRense is e pstty misdemeanor,fsllure to app�ar will b�considsred a plss o(puilty and
weiver to the ripht to trial unleea the feilure to eppsar is due to circumatancea bsyond the
pereon's control(M.S.1o9.91).
Appeal
To plead not puilty,or to plead puilty and oRsr an sxplanation� , �
1)ARer 3 6uelness days,cdl 661-266-9202 to conllrm tha[the citation has been flled
with the court.
2�If th�cltatlon has beon fll�d,nqwet�h�rrinp offic�r appointment.
3)When you errive at the Violation�Buresu,tell the ceehier that you have a hearinp
ofticer eppolntment.You must have�photolD wlth you.
I undsrstand that by PA'YING THIS FINE I AM ENTERING A PLEA Of GUILIY to thie oRenso(s)
and voluntarlly waive the followinp ripht to:
A.a trial to the court,if oRense ie a petty misdemeanor,
B.a trlsl to the court or to aJury Itths oRense Is a misdemeanor, ,
C.representation by counsel, , •
D.a pnsumption of Innocence untll proven puilty b�yond a reaeonabl�doubt,
E.confront and crose-szamin�ell witrnases apainst ms,snd �
F.alther rameln ailent or to teatlfy In my own behalf.
I also understand that if this oRense Is a petty miademeanor,the maximum poscible sentsnce is
=30090;if thin oRense ia a miademeanor,the maximum poeaible sentsnce ie i7,000.00 fine
endlor 90 daye Imprlaonment.
citation No.: E 20901274318
I
i
. � �
. � ;
u� ���
�
� ,
� � � �
�- �
� f
� � �� � � � 1 i �
� O �) C� � ^ N f�- O i�- � f.-;
�
C
I i
.� � � � � Q � � � � �
� � T : ' L
� r fft 63 ff'-J' fA E!9 Ef-? ff� i �!
�: � � I ��
� �: � � '
�
� ` � � ��
� � � � � � �, �i
� {�; .i tL � -� � � � �� `,.+�t..
� � � . � � ?,
� C� J +i� � ' s :11
� � � �� _ � � i � ��
� �f � � .� u C'� � � '� �j!
� � iv � X � � '�L'j
,
� � �;a1 F-- GJ �i t-- U} �l F— Z �F
�� �,, _"�.. c�,�
� �'`= - �� �
r a� .... a� � �� �
� � � � s ' ��i �
C :
,� � � � � ,� �� r
i � � � � n ', � �&
� � , �►
�3 �- -� � � �' —� k ! � z� i
� s � o � = -� - ; � r.�
� � �n �, :.J '� � � � �i..
Z � � � �
c� � �' v ,�' ;;� � " f C.� �• �
L � � � �� �1
� �-- � �, _ --. ,
,�w1 � 1-- � '� � �% � d � .�-- ��
� il} .^' sy C � � �
R
{� � � � d � � � a � �!
v` `�.�) � � � Z� V CPi �. � ��
� � s„� "�'3 � ,,;_ � � � i � P, �i
� � � — � •— � L:
� � � � r . � � " � �' � ;
� � � � � ^ � � �t°s � �
� � � � � � � � �
� G � :.i t'" � � r— •�" � L"?
� � 7 � `� � � � � �. ; � �
� a � � � � � � r � � ( � '
� �'. �-, ^� U 5 fl: %�' �. `� Q) .,,�.,, �
:�3 'ci � —' � :� � G � :� � � � �
,Z ,,r; �„ i� .� � �; � n , ;,� ,
G � '� �.:.J � N � � � � O L i � �i
� � � � -t- CL � Q; � �- p '� C F--,
�" C,F? � � ia C7 .,.. �- �y -C (..3
� "' C's Q .G L � � �` � � t'��0 � � r�
t V �_ w` "� � �' � � �! J � L
s3. ° � cy �; -� a � � � .� a� � v^ �
� � � � ro � � � � � �� � � � �
� _� � c� -� �? �; = �, c � .� � � 3" �
�/�� Gc� m v�/ � � � � � �; a � � � Oi �
V j C � 1.:.. �i � .�. .� � Q.. � ai J
�
�� 1
� �
�
�
�