Sherman � �:i
' �s����r.�c�ao��s �or �ili�e� �o�ic� o� �(ai�� ta �E�y af Sainf Pa�l�
Minnesota State Statute 466.05 NOTICE OF CLAIM...(E)very person...who claims d� ffc��/,��
municipality...shaU cause to be presented to the goveming body of the municipality within 180 days after the �
alleged loss or injury is drscove�ed a notice stating the tlme, place, and circumstances�re�a�i��e amount of
compensation or other �elief demanded. !
CITY CLERK
Please complete tl�is form in its entirety by typing or printing your answer to each question in
the space provided. If additional space is needed, please attach additional sheets.
� � PLEASE RETURN THIS Office of City Clerk
COMPLETED FORM TO: 170 City Hall
i 15 W I<ellogg Blvd
St Paul MN 55102
Your Name: �( � O J� ��'7' ��/�/��v '
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- Street-Address:--f�j �___ tit,f_, - /��`��v�//��"7 -�- --�l� /"---- __--- -- --
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City: State: Zip Code::.����
Daytime Telephone: /� ^�y�^( �...��..�Evening Telephone: ( -�1'����/�n
Date of Accident r Inciden ;Gi -Jd�'�l��ay of Weelc: �1��� Time: �,/��am or pm (circle one) . ,
Please state, in detail, wf�at occurred and the circumstances surrounding the event. Indicate how the
City of aint P ul �s involv , and why feel the it responsible
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Please indicate your reason for completing this form: �
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f:=1 Veliicle accident l:7 Other property damage (please �rovide specifics below) ';;;;i`I�
� Vehicle was towed ���� �� "i��
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❑ Vehicle damaged ❑ Other i�jury to person (please provide specifics below) :,,���;:
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❑ Slipped and fell. on City property �'� '
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Please provide the names and telephone numbers of any City employees involved in this i ;'
ncident ccideQnt and how they�ve��olv�d��� ��� �Q ; �
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lf your vehicle was involved, please complete the followin L
Year, mal<e, and model: �g�g ���id � 2�� License Plate Numbee: /���K
Extent and area damaged:
Was a City vehicle involved in tl�is acciden /inciden , es No (circle one)
If yes, please complete the following: Type of vehicle ��lJU '(iC- V � '�\
Year, mal<e, and model �
' Color of vehicle License Plate Number: -
Description of vel�icle
Location of acciden incide t (please provide specifics sucl� as street address, intersection, cross streets,
pa� �e,,f�il�y� �tc.)• W� ��/�s��l"����� �j f/.�
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Please.draw_or attach a_diagram.if_applicable:
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Please specify the nature and extent of tl�e compe sation relief you are requesting. Please
attach copies of any bills, receipts, ticl<ets, or other documents to support your claim. If you are
claimi damage to a vehicle, please submit two estimates. *
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Were_there witnesses to this accident incident? es No (circle one) :
If yes, please ive the n es, addresses, ancl telephone numbers of the witnesses:
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Were the police called? Yes � (circle one) If yes, what department or agency? �
Police report number: =
Please print the name of the �l '
person comptetin this form: �i� � �], ��/�i���� -
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Piease sign your name: l _ - � L �!L �2�'/h�' e�
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Date form s gned: C_-� � � ��� — � � � �
�isl< Mgmt Division - Revised 1-30-01 ;g{i��',��(i'
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. ' St�t� of Minr�e��ta Rams�y Distri�t C�urt
�.- � CITY OF SAINT PAUL
PARKING CITATIC)I�
citatian No.: 620900754751
Case No.:
St.Paul Police Department _
Vehicle License Number: 999I°I.J K State: M N USA
�an��ie viN:
. Make: FOR� Model; NOT IN LI5T Golor; BLUE
Type: PASSVEH
Tab Month: Tab Year:
Date 8f Dff�nse 6l6/2013 Tim�af Offence 11:00
. Statute/�rd Offense
'157.t13��.�D P��k v�Fl cl��t��rne ic�cati��t��r�e tt���4$G�i1��e�tiV�
hours-
1 G9.34.1{a)(6) PARK WJI 20'!tJF X-WALK
�ffense Location:
1396 MINN�HAHA AV E Intersecting Street,
2nd Cross Stre�t:
Of'fense City:
St. Paul
Meter Number: Permit Zone: •� Signs Vis:
�h��k��,: �hafk�ut: Parked: (HH:MMj T�m������
Unit: 961
officer 1: PEO R.Burgos
Offieer Nurtmb�r: 8fi401
Officer 2: .
Officer Number: '
Report d�fe�tive met�rs t�y noon the next business day
C�II(fi5'I)��fi-9776
To pay your fine by credit c�rd,wait�business day�and then caie
(65'I)268-�2�2
If cited far Na Proof bf In�urar�ce or No Drivers Li�er�se ih Possess�an, Prbof of Insuran��and/or
� � Drivers License shoutd be shown in one of the Violations Bureau Locat9onx tisted below vu?:ti+n
3�business day�of the'vidlation.
s,:;;
To payyour citation onlin�e: www.2ndwebp�courts.state.mn_.us
For additional information or to pay your fine by telephone using a credit card,
cau: �ss��2ss-s2o2.
Please have your citation number and credit card available.
Mail payments to: Ramsey District Court
Traffic i/iolatlons Bureau
15 WRSt Kella�g Boulevard-Room 1�0 � �
St. Paul, MN 66102-1813
Make checks payable_to� Ramsey District Cou�t
� (A charg�of up to$30.00 will be assessad on all retumed checks)
-�
Violatians Bureau Locations
� St. Paul�ourt Suburban Gaurt Lavv Enforcement Cente�
�15 W. h�llo�g Blvd. t�M 130 �QSd Whita 8ear Rve, 425 Grave�treet
St. Paul, INN 55102 Mapleuv�od, Mh155109 St. Paul, MhJ 55107
Office Hours:8:00 A.M. -430 P.M. Monday-Friday(Excluding Holidays}
• aearir�g Off�c�rs: �j°��ipoii�tirent anly�eall(fi51}-2fi6�202
Payment and Penalties
If you wish to pl.:ead guiliy for the affenst{s}on the reverse side af the citation,you must do so
within 30 day�fr�tti tt�e date tFtie�ifatioil I$fil�t!vti►1tN th�C�i.rt. It i$y�ur resp�n�ibility tb
present your payment n a timely manner. Pleasa aliow 6 business days for processing.A$6.00
lat�f�e is a�d�d td aU�np�id fine��I�nc�s.ARer d�day�trom tFie date th�eitati�in i�fil�d with
the Court additional�ielinquent fee�ma�;be added ta all unpaid f ne amounts.
Additional penalties may include: 1)referra�l to the Department af Public Safety for driver's
license suspension,2)arrest warrant issued, and/or 3}roferral to a collections aeency.
If the or'Fense is a petty misdemeanor,failure ta appear will be considered a plea of guilty and
waiver tti the risht t8 trial ui�less tNe failur�tb a�pear is du�t8�ircurt5sts�nces�,�yand t�i�
person's control(M.S. 169.91).
Appeal
' To pl�ad not�uilty, ar t�ple�d guilty and affer an explanation:
1)Afttr�i business days, caii 66'I-�66-920�to confirm that the citation has been fi�ed
with the court.
2)If the citation has been filad, request a hearing afficer appointment.
3)Wh�i�y�iu�r�iv��t the Vt�latio�i�Bi.ir��u,t�ll the��s�ii�t'tFiat y�u f5�v�$he�r'i�i�
officzr appointment:Yau must have a photolD with you.
I understand that by PAYIN�THIS FINE I AM ENTERING A PLEA�F GUILTY to this offens2(s)
�nd voluntar�ly w�lve the f�llawi�ig right t�:
' A. a trial to the court, if offense is a petty misdemeanor,
B, a trial t�the court vr to a jury if the offense is a misdemeanor,
C. re�r�scntatiar��y caunsel,
D, a presumptiv�of innocence until provan guilty beyand a reasanabls doubt,
E. ��,i�frbr�t ai�d�rb��-exarr�ine�II witi��s��a�g�inst m�, ar�d
F. either remain silent or to testify in my own behalf.
I also understand that if this offense is a petty misdemeanor,the maximum possibla sentence is
$300.00; if tt5i�off�iise is�titi3�Jemeanor,the m�xiri'tum p�issibl�s�t�t�n�e i�$1,000.00 ffile
and/or 90 days imprisonment.
�
' �itation No.: fi2090075475�
. Saint Paul Police fmpound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 78 FORD License#: 999HJK CN: 11113978 Invoice#: 14�96
Date/Time Released: 06/06/2A13 21:09 Tow Charge: $ 54.50
�
Released to: OWNER Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: PERLITA Tax: (7.625%} $ 10.26
I,the undersigned,have recovered the vehicle des ribed above. Subtotal: $ 144.76
I will check the vehicle for damage or any other pr blems that
may have occurred while this vehicle was in the c stody of the Service Charge: $ 0.00
Saint Pauf Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: _ $ 144.76
on this form prior to leaving the impound lot.
Damage and/or other problem:
�
Police Report made: Yes�No,_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS, REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5/2000
Signature
�
Saint Paui Police impound Lot, 830 Barge Channel Road, Vehicle Release Form .
Make: 78 FORD License#: 999HJK CN: 11113978 Invoice#: 144696
Date/Time Released: 06/06/2A13 21:09 Tow Charge: $ 54.50
r
Released to: OWNER Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: PERLITA Tax: (7.625%} $ 10.26
I,the undersigned,have recovered the vehicle described above. Subtotai: $ 144.76
I will check the vehicie for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowiedge I will report
damage and/or any other problems to the Impound Lot staff T'otal Charges: _ $ 144.76
on this form prior to leaving the impound lofi.
Damage and/or other problem:
Police Report made: Yes�No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS, REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature 5�2000
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