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Jackson RECEIVED NOTICE OF CLAIM FORM to the Ci�� Paul, Minnesota Minnesota State Statute 466.05 states that"...every person...who claims da�wg��i frbm b��tv...shall cause to be presented to the governing body of the municipality within]80 days after the alleged loss or injury u discovered a natice stating the time,place,and circumstances thereof,and the arnount of compensation or other relief demanded." Please complete this form in its entirety by ctearly 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 compensatlon being requested. You will receive a wrltten acknowiedgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your claim. Tlus 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 � —` ��c�csa� First Name� `�� Middle Initial V Last Name Company or Business Name !� �� Are You an Insurance Company? Yes� If Yes,Claim Number? �� Street Address � � ��' City v�✓ G��2 State �� Zip Code� Daytime Phone(�� D 5��3 Cell Phone �) - Evening Telephone(_) - Date of Accidend Injury or Date Discovered��.�� Time ��'-3d a pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel t�City of Saint Paul or its mployees�e invo�d and/or responsible for your damages. �c � � �..Q �— � �� , c,1� , �' �.�%in a � wi Cmc. a 1•�� 3.c� � 'f''��+ n Please check the box(es)that most closely represent the reason for completing this form: 0 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 �Iy vehicle was wrongfully towed and/or ticketed ❑I was in'ured on City property ❑Other type of property damage—please s�ecify � 3 c°�� ❑ Other type of injury—please specify �c In order to process your claim You need to include conies of all apulicable 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 estimates for the repairs to your vehicle if the damage exceeds $5 00;or the actual bills and/or receipts for the repairs "'�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 and return both pages of Ctaim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-olease complete this section � Were there witnesses to the incident? Yes No nknown (circle) Provide their names,addresses and telepho numbers: � "�'Z�� d'�O 7�/- �� nn M 4(Sfl Ya u.� " ) Were the police or law enforcement called? Yes No\ Unlcnown (circle) ff yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide st�eet address,cross street,intersection,name of park or facility, closest landmark,etc. Please be detaile as ossible. ff necessary,attach a diagram. 13 4 7 La•�^�c 1 /�s�— , �vl+ �,� ; 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. y`�� i+� �St-rr•�ir.# Vehicle Claims- lease com lete this sectlon O check box if this section does not a 1 Your Vehicle: Year 00 Make S� Model 92� License Plate Number State�If`1 Color ��w� Registered Owner ' r` �. 3uc:.��s�-. Driver of Vehicle '�'i � =c�sc�. Area Damaged City Vehicle: Yeaz Make Model License Plate Number State Col r Driver of Vehicle(City Emplo s Name) Area Damaged I u Claims- lease com lete this section ❑ ch ck box if this section does not a 1 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 yon are attaching more pages to this claim form. Number of additlonat 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. ' Submitling a false claim can result in prosecution. Date form was completed �1�'//� �� _' Print the Name of the Person who Completed thi : ��'r i GL�1 J G G�$C'� r Signature of Person Making the Claim: � �� Revised February 2011 ' ��I��INI'� Page 1 of 1 ��IIIII�� (NC 6/21l2012 �DENT INF�RMqTION REP�RT STATE pF M�NNESOTA C�UNN OF RAMSEY DISTRICT COURT INCIDENT AND CITATION INFORMqT�ON INClDENT ID PAYMEN7 PLqN I 2320609 CITATIt�NUMBER DEFENDANT NAME BRIAN JEFFREY JACKSON 888�4�36 ADDRESS 1397 LAURELAVENUE . I DEFENDANT INFORMATIONAUL MN 55104 DATE OF BIRTH g/22/�gg1 HEIGHT GENDER WEIGHT EYE COLOR OL STATE MN RACE DL NUMBER R828134324918 OFFENSE INFORMATIQN H�SPANIC(Y/N) i DATE/TIME 02/29/2012 22:30 DIVISION RAMSEY COUNTY LOCATION IFO 1397 LAUREL COMMUNITY ST PAUL AGENCY PUBLIC WORKS METER ISSUING METHOD OFFICER 1 714 CN �2p47p44 OFFICER 2 NBRHOOD VEHICLE INFORMATION PLATE 174ABZ MAKE SAAB STATE MN MODEL 4 DR PIATE YEAR 2012 COLOR BLUE VEH TYPE VIN JF4GG22655G050617 VEH YEAR RESPONSIBLE PARTY ID METHOD NONE OTHER SYSTEM IDENTIFIERS � CN NUMBER CHARGE INFORMATION STATUTEI STATUS REASON JURISOICTION ORDINANCE DESCRIPTION CLOSE OTHER STPAUL 161.03 Snow emergency parking restrictions ORIGINAL FEE INFORMATION AMOUNT DUE $40 FINE 40.00 $40 FINE LATE FEE 5.00 LATE FEE .00 25.00 LATE PENALTY •�Q LATE PENAITY QO Srchrg-2nd District 1.00 5rchrg-2nd Dist�ict Srchfg-Parking 2009 12.00 Srchrg-Pa�i�g 2009 •00 GRAND TOTAL 83.00 GRAND TOTq� .0� .00 OFFICERS COMMENTS POSTED NIGHT PLOW;TAGGED BEFORE PLOW