Roubinek P(CI�CI V CV
APR 05 2013
NOTICE OF CLAIM FORM to t��t;�%���t Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality 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."
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 explain 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 k.2��- Middle Initial S Last Name 1Z�`� Q'��-
Company or Business Name
Are You an Insurance Company? Yes/No If Yes, Claim Number?
Street Address ��2-`� P5`2T(�'`'� R`��' �` 3C�"
City S�• P��'� State '(�� Zip Code S S 1�4
Daytime Phone (_� - Cell Phone (�( ��-).��- �`� Z�'Evening Telephone(_) -
Date of Accident/Injury or Date Discovered Zl � M�(�-� �� Time "�`�' a�r I 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. ot� 2$ !`��� I,�
M`-1 1�l�tU-E'L ww�� C..��>���-�-`1 �� t�'�� .�.: .'FiZc,u� �t ;)v.�-t t-h��tr.�C-• Tl"�t-
�}"�`1 Z�e`.2�a.� i T� C��1�� C Sd.�- ��fVtc�L� t��e v..�..�S �t�T '��L M��'''L-
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�� �.J�� 1[v"�� t�� !�`�.. 1'� /{J ( />>4J �"i C�i�� � / � ��-P-„'UC,� �/— C:,1J .�tJJ,
i.,�.R.5 '�w1.1� c �i�tt-�-� G�.�.t+� �T- fl^^, �t%i'�k't'`'4 �,1�"�(3<;.�b�"•i.s-�`r t-�2. il�lt�� N�r.���
�� �� i: i ;,a�,a,-,..r�r F./'�!% (.� ��^�'�Z'�
c.i:�t.(� c-Lt-��- c:.�%T
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
�❑ vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
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 WILL 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 estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or 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 dari±laged 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 and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please comulete this section
Were there wimesses to the incident? Yes No Unlrnown (circle)
Provide their names, addresses and telephone numbers:
��
Were the police or law enforcement called? Yes � Unlrnown (circle)
If yes,what department or agency? Case#or report# (�'2���n�G� o�:`�
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.
I524 {��0`Cz�-� R�;� S<< R!��� r�r�
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims-please complete this section ❑ check box if this section does not apply
Your Vehicle: Year ����4� Make gti^��% Model SZ5�
License Plate Number �b2�-K. State w� Color (�.;,Zti;-
Registered Owner -i�2�� 6Zv��i:"'�-
Driver of Vehicle -
Area Damaged —c--�w�-
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims-please complete this section �i 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 Q' .
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 � ����" ( 3
Print the Name of the Person who Completed t ' . i�2 ��- ��`�t�3; �U�,IL
Signature of Person Making the Claim.
Revised February 201 1
PARKING CITATION
citation No. 620900701009 r������ ��^
Caee No.:
gt,paul police Department
Vshicle Licenss Number�. �62KxV
Stata:W�USA
Vehicle VIN:
Model�. Color:HAZEL
Make:BMW Type�.PASSVEH
Tab Year:
Tab MOnth'.
Date of OfFense 312112013
Time of OfFense 08:00
ORense
StatutslOrd — -
157.03.a20 Park venicle at same location more than 48 consewtrve
hou�5-
r ffense Location�.
1�36 PORTLANU AV Interseccing Street-
�.ntl Cross Street.
uRenss Ciry:
St Paul Siqns Vis:
permit Zone'_ Time Zone�.
MeterNumber. ChalkOut, Parked�. (HH�.MM)
ChaIM In.
Unit 9Tt
prncer� PEO N.Rosenberg
pRicer Number. 585005
Ufficsr Z�. .
OfBcer Number�.
Report defective meters by noon the next business day
Call(651)266-9776 s and then cail
To pay your fine by credit card,wait 3 business day
(651)286•9202 —__-
__
������ag�i ens r sY ould be shown in one�of thz Violatfons Buseau Locatons listed below w'Rhin�r
21 businass days of the violation.
To pay your citation online v�+-?ndwebel:�aurts state_mn,us
For additional information or to pay your hne by telephone using a credit card,
CaIP. (661)26892���
please have your citation numbzr and credit card available.
Mail Payments to-. Ramssy�ietrict Court
TrafRc Violations 8ureau
16 West hsllopy Boulevard-Room 130
St.Paul,MN 66102-1613
MaMe chec!ee payab�e to- Ramsey District CouR
(A charpe of up�0 530.00 wJl be assessed on all returned checks)
Violations�Bureau L ocations Law Enforcement Center
Suburben Court q�Grove Street
St.Paul CouR 20b0 Whlte Bear Ave. gt paul,MN 56101
15 W ��e��o�p 81vd.RM�3� Maplewootl,MN 56109
St.P'�I,MN 65102
pfficeHours�.8�A0A.M.-4�30P.M. Monday-Friday(ExdudinpHolidays)
Heariny OtFlcers.�y appointment only-call(661)4669202 ___ ___
_ �—_—_ _
payment and Penalties ou musc do so
If you wish�o plead puilty for the offanse(s)on tho reverse side of the citaeion,y
msnt n a timely manner.Please allow 6 business days for Frocessinp.A 56.00
within 21 days from tha date the ci.ation is filed with ths Court It is your responsibility o
presentyourpay
thz Coulrt add taonal Idelinqu n1t feeslmav be added to 1 unpa d fine amountstation is flled wi
Additionai panaitlas may include.1)referral to the Oepartme�t of Public Safery for dnver's
license suspension,2)�-�rest warrant issued,andlor 3)referrel to a collections ayencY-
If Ihe offense is a petty misdemeanor,failure to appear will be considered a plea of puilty and
wajver to[he riyht to trial unless the failure to appear is due to cirwmstances beyond the— --
person's control(M.S.165.91). _ _ . ___--.------
-_ _ _____ -APpeal
"o plead not Uuilly,or to plead 9"11661 2669202 toclonf rm that the citation has been filad
1�ARer 3 business days,c
with the court. ointment.
2)If the citation has been filed,raquesl a haarinfl off�sr app
3)When you�a'n,mant`You must have arphotolD with yo ier lhat you have a hearinp
oRicer aPP ---- .�. -. .-
I understand ihat Dy PAYING THIS FINE I AM ENTERING A PLEA OF GUILTf[o this offense(s)
and voluntarily waive lY�e followinp right to�.
A.a tnal to the court,if oRense is a petty misdemeanor,
_ . ._,._....�..��n or to a iury it th�e offense is a misdameanor,
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Receipt ID:�r Drawer iD:���_ r� Payment Date_�—
Payment Amount:�— Batch ID: 59941 ���� Cashier ID: switalal
Payment Method���� Lacation: VIOLATIONS BUREAU � Refund Amt: 0.00
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;�ald ����� ��yl��i��4t IU9arch 1�, 2013 fio April 4�, 2013
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Date Description Amount
_ _ __ __ , _ .
0�/01;2�i3 `.'•�:`� FRANCE 44 FOODS 5429MlNNEAPQUS Mi•t 10.69
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03/19/2413 � _;:s SUPERr�.MER!CA 4356/UPJST PAUL MN ?�J2
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1 - �5 of 5� Transactions
Previc�us Baian�e as of 03111f13 2,618.53
��y€�er�ts -2,fi1�.53
G�t��g�� 2,��5.49
�=ees d.C4Q
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