Lofgren NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
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 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."
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. ff 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 i 1Q`��l�1;U t�.� Middle Initial�Last Name L�r��-��v � (�(������
Cc�mpam•or Business Name nrT � ,7 2��3
Are You an Insurance Company? Yes/�o If Yes,Claim Number?
Street Address � �.�v L E R K
City `J � � 1 CLcLQ State �/� Zip Code 5 � � �
Da time Phone ��
y (�'S�)��� ���Cell Phone( � � ,_.� Evening Telepbone( �� ' �
Date of Accident/Injury or Date Discovered G / / Time ��' Q a 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 e ployees are involved and/or responsible for your damages.
� +Cc oT CL� ��� `kS i�2��ti� `��,r U. � ( c V i ,P
G. �N 1 r� r'►1 G �C ' `��l i rY�G�t�! 1 rti.1 "r U .�r' . � 1'
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Please check the box(es)that most closely represent the reason for completing this form:
O �1� �ehicle w�as damaged in an accident ❑ My vehicle was damaged during a tow
p \i� �ehicle ��as damaged by a pothole or condition of the street ❑ 1�vehicle was damaged by a plow
:=1 � �ehicle was w rongfully towed and/or ticketed ��was inju�ed on City property
� r t}-pe of propeRy damage—please specify�' �{�'1��U��'
Other type of injury—please specify 5 Q�f���i�,��,�,� �
In order to process your claim you need to include conies of all anqlicable documents.
F.�r the rlaims t}�pes listed below,please be sure to include the documents indicated or it will delay the handling of
��wr�I:�m. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
:r�} f��r�our�lf before submitting your claim form.
O Property damage claims to a vehicle: two es[imates for the repairs to your vehicle if the damage exceeds
5�00.00; 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 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-nlease comnlete this section �
Were there witnesses to the incident? Yes No Unknown (circle) �
Provide their names, addresses and telephon�e um�,J�ers: ��`fn,C.`���12�CC�
� �`� `/!�'��"� � `
Were the police or law enforcement called? Yes N�o Unknown (circle) �
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest 1� dm k,etc. ease be as detailed as possible. If necessary,attach a diagram.
1 r L �` I I.� S 5 �
Please indicate the amo t you are seeking in compensation or w at you would like the City to do to resolve this claim
to your satisfaction.�_�CiC� 6�`
Vehicle Claims-alease comnlete this section 1G check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims- lease com ete this section ❑ check box if this section does not a 1
ow were you injured? � �'.L2� ' 1 �'� �
� v �
What part(s)of y ur b dy were in ed? � �
__. .___.,_ �
Have you sought medical treatment? Yes No Planning to Seek Treatme t(circle)
When did ou receive treatment? �7 ° �-_ —'
Y (provide date(s))
Name of Medical r vider(s): � �
Address �. ��tY�'��' /1 Telephone
Did you miss work as a result of your inju � Ye No
«'hen did you miss work? ��� (provide date(s))
\ame of vour Employer: � �L •
Address l Z�' 1 ° " Cut�' : S���. TelephoneG�/-&S� -y Yyy�
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.
I�/� /�
Submitting a false claim can result in prosecution. Date form was completed �/�.9//J� -3
Print the Name of the Person who Co this Form: f� �t/ — • L. {�
Signature of Person Making the Claim. ���
Revised Februazy 201 I
October 1,2013
City Clerk
15 West Kellogg Blvd � �
310 City Hall
St Paul,MN 55102
What was done at my home,to my 50-60 year old black walnut tree has caused
irreversible harm to it,my property&home,and to me.
This was a traumatic event,like a tornado copming through my yard,but this was not an event I
of nature instead it was a methodically planned,malicious event which resulted in the ''
massacre of my tree,the die off of hundreds of dollars of shade perennials and grass on my
property and an invasion into the very security of my beingLy home.This tree,my house
� face west. Now my yard and home are open to the blaring west sun and to all the nasty and
irresponsible behavior of everyone in my neighborhood. So far,in just a week's time,I have
had people walking their dogs in to my yard,letting them poop and picking flowers from my i
gardens. i
I have been discriminated against.No one else's on my street or up and down the parkway has
had their trees or shrubs massacred, even trimmed. I have attached photos in evidence.
1 have had to go to the doctor for stress relat�d symptoms do to this traumatic event and
treated with medicine that costs 1.00 per pill,which my insurance does not pay for.I have had
a headache since that fateful Friday the 13th. I can no longer sleep at night due to this violent
traumatic action at my home,worried every minute about who is coming into my yard and i
looking into my bedroom and living room,they could not do this before. �
I have spent my house payment money to plant a barrier of grasses and panels to protect my �
yard,my house,ME.This is only on the ground level. Now there will need to be heavy _
expensive draperies hung in my house to protect it from the hot summer sun as this tree was '
clear cut from top to bottom,protecting home. I have tried to have a conversation with the
Parks supervisor,asking for what my neighbors have planted by the city in front of their
homes and he will not return my call,discrimination once again. .
�
It is very hard to go to work,I do not know if I can any longer as I am afraid to l�ave my home;
I went to Walgreens for 15 m
inutes and came home to this traumatic massacre site.I have
lived in my home for 30 years and the city has never trimmed this tree.There was no
discussion,no notification,no opportunity given to me to take care of it in a healthy humane
manor. I trim it as best as I can every year! I would have worked on more of it if I had been
asked to; notified by the city,I was not! So what I have lived with as normal in my life for ;
30 years was ripped away in 15 minutes by an unskilled city employee who told me he doesn't _;
think,he just has an order to follow. I have had an arborist look at this tree and he states it �
needs near$500.00 worth of trimming to level it out,loosing more of the tree.Also,since I
have complained about what has happened I have been threatened with this statement"Xcel
will still need to cut more for the wires" I am sure this will be to the extreme as well in
retaliation for my complaints. '
— -t
`�a'�' -_ - ,�- ,
I was Mld so many bulling double standard st tements by the city in trying to justify this
massacre.I will take issue with one here which is them trying to tell me a limb from my tree
could have been in the way of an emergency�ehicle. I have lived in this home for thirty years
and not once has a vehicle been detoured.An�l as you see from the pictures ther�e are trees
hanging in the street at far more of an extent then mine.
I have watched as my neighborhood has deteriorated and the Parkway in front of my
house has become more and more of a zoo,I call the city&police about what is going on
out t6ere because I care but there is no recourse for the bad and illegal behavior.
....................and then...................
I always have been a responsible citizens and neighbor for 30 years at this home and
for the last 21 years I have tried to take care of my home by my self,to keep things up, ;
exhausting my self physically,financially and personally,struggling to even make the
house payments.I am rewarded for my good behavior and responsibility by this total
breach of irresponsibility and harm by the city,because it is more important that
trucks and cars can drive by and right next to the curb a 40-50 miles an hour(on a
30mph street) then anything else!
You have lost a resident that cared.
� i
�
Rosanne Lofgren
1468 Furness Pkway �
St. Paul,MN 55119
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Photo Index
A. The curbside of my home showing how there is now not a leaf or branch left.
Also, showing how this is not the standard for anyone else on the parkway or
through out the neighborhood. I have been discriminated against.
B. Photo of limb cut back over the easement and onto my property.
C. The hedges and tree of the person who loves right next to me (north) who
has shrubs and trees hanging over the curb and into the street.When I asked
the city about this they sent a letter to them to trim. I DID NOT RECEIVE A
LETTER! Now it is sort of cut but NO WHERE NEAR THE DEVASTATION
THAT WAS DONE TO MY PROPERTY.
D. City tree on Parkway that is right across the street from me hanging out
further into the street then mine was!
Photos 1 - 5 are samples of trees hanging over in to the street all over my
neighborhood. Number one shows how much so that they meet in the street and
totally block out light. I have been discriminated against. No one else is held to this
standard that was traumatically forced upon me without notice!
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2360 WHITE BEAR AVE. � 2360 WHITE BEAR AVE.
' MAPLEWOOD, MN 55109 (651>770-9600 MAPLEWOOD, MN 55109 (651>770-9600
2801 00022 12678 09/21/13 11:36 AM 2801 00022 14310 09/21/13 05:22 PM
CASHIER ELIZABETH - EXV1069 CASHIER TERRY - TMV1355
0870q826q014 6' FRAMED <A> 23.36 087048264014 6' FRAMED <A>
6' REDWOOD FRAME DIAMOND TRELLIS BRN 6' REDWOQD FRAME DIAMOND TRELLIS BRN
2�23,36 46.72
SUBTOTAL 23.36 �UBTOTAL 46.72
SALES TAX 1.66 SALES TAX 3.33
XXXXXXXXXXXX3953 DEBIT $45.02 TOTAL $50.05
AUTH CODE 26196q XXXXXXXXXXXX3953 DEBIT 50.05
AUTH CODE 661522
CHANGE DUE 20.00
IIIIIIIIIIIIIIIIIIIIIIIIII�I�II IIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�II '
II�IIIIIIII�I�I II�III III
2801 22 12678 09/21/2013 5231 2801 22 14310 09/21/2013 5231 ,
RETURN POLIGY DEFINITIONS RETURN POLICY DEFINITIONS ''
POLICY ID DAY5 POLICY EXPIRES ON POLICY ID DAYS PQLICY EXPIRES ON �I
A 1 90 12/20/2013 A 1 90 12/20/2013 '
THE HOME DEPOT RESERVES THE RTGHT TO THE HOME DEPOT RESERVES THE RIGHT TO !
LIMIT / QENY RETURNS. PLEASE SEE THE LIMIT / DENY RETURNS. PLEASE SEE THE
RETURN POLICY SIGN IN STORES FOR RETURN POLICY SIGN IN STORES FOR
QETAILS. DETAILS.
BUY ONLINE PICK-UP IN STORE BUY ONLINE PICK-UP IN STORE
AVAILABLE NOW ON HOMEDEPOT.COM. AVAILABLE NOW ON HOMEDEPOT.COM.
CONVENIENT, EASY AND MOST ORDERS CONVENIENT, EASY AND MOST ORDERS
READY IN LESS THAN 2 HOURSI READV IN LESS THAN 2 HOURS! �
��������������������������������������� ���������������������������������������
ENTER FOR A CHANCE EhlTER FOR A CHANCE
l0 WIN A $5 , d00 l0 WIN A $5, 000
F-IOM� DE��On! GIFT F-IOME DE�RD! GIFT
Share Your Qpinion With Ust Complete Share Your Opinion With Us! Complete
the brief survey about your store visit the brief survey about your store visit
and enter for a chance to win at: and enter for a chance to win at:
www.homedepot.cam/opinion www.homedepot.corn/opinion
COMPARTA SU OPINION EN UNA BREUE GOMPARTA SU OPINION EN UNA BREVE
ENCUESTA PARA LA OPORTUNIDAD DE GANAR. ENCUESTA PARA LA OPORTUNIDAD DE GANAR.
�.1�er ID : U��r ID :
2S�{4 .Fi 25657 31710 28931
F�assword : F'assward :
13�'471 25645 13�171 28909
Entries must be entered by 10/21/2013. Entries must be entered by 10/21/2013.
' Entrants must be 18 or older to enter. Entrants must be 18 or older to enter.
See cornplete rules on website. No See complete rules on website. No
purchase necessary. purchase neaessary.
M+ar� �a�win�. Mar� �avin�.
a �+1+�r� +d�ing;'' c� �+1�r+� +d�aing;"
, MAPLEWOOD 6MNW561096EpR651)770-9600 MAPLEWOOD��MNw5S10gsEAR651E770-9600
2801 00022 2358q 09i26/13 02:44 PM 2801 00022 22982 09/26/13 11:31 AM
CASHIER ANDREA - ANV2714 CASHIER ANDREA - ANV2714
08704826q014 6' FRAMED <A> 048307010q14 PLANT STAKE <A>
6' REDWOOp FRAME DIAMOND TRELLIS BRN PLANT STAKE STURDY 6FT
3�23.36 70.08 6�2.97 17.82
0000-6q7-185 EARTHGRO BRW �A,S> 0q8307010421 GARDEN STAKE <Ay
2 CU FT SCOTTS EARTHGRO BRN MULCH 6' STURDY STAKE HVY pTY GARDEN STAKE
4�2.50 10.00 2@3.97 7.94
SUBTOTAL gp,pg �486 7X6164�BAMSOO�REED GARDEN FENCE�47
SALES TAX 5.71 651$40600006 #2 GRASSES <A>
TOTAL $g�,79 #2 GRASSES HF 1EA
XXXXXXXXXXXX3953 DEBIT 65.00 2912.88 25.76
AUTH CODE 860616 20.79 022401005712 METAL STAKES <A> 3.97
METAL ANCHOR STAKES 4PK
032247623735 MGPOTTING <A> 9.97
1.25 CU FT MIRACLE GRO POTTING MIX
IIIIIIIII+II�IIIIII 649398219016 32"FENCE <A>
I IIIIII�IIIIIIIIIII 32" CATHEDRAL FOLDING FENCE GREEN
�IIIIIIIIIII IIIIII 2Q13.47 26•94
2801 22 23584 09/26/2013 2024
SUBTOTAL 116.87
RETURN POLICY DEFINITIONS SALES TAX 8.33
A POLIiY IQ 90YS POLICY EXPIRES ON CASHL $126.0
THE HOME DEPOT RESERVES THE2RIGHT3T0 CHANGE DUE 0.80
LIMIT / DENY RETURNS. PLEASE SEE THE '
RETURN POLICDETAILSIN STORES FOR IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiIilIIIII
IIIIIIIIIIII
BUV ONLINE PICK-UP IN STORE 2801 22 22982 09/26/2013 2024 . �
AVAILABLE NOW ON HOMEDEPOT.COM. �
CONVENIENT, EASY AND MOST ORDERS RETURN POLIGY �INITIQWS i
READY IN LESS THAN 2 HOURS! POLTCY ID DAYS pOLIC�25X20R3S ON
���������������������r�������x��:�������� A 1 90
THE HOME DEPOT RES�RUES��E RIGHT TO '
E N T E R F O R A C H A N C E LIMIT / DENY RETURNS. PLEASE SEE THE
T O 'WI N A $5, O O O RETURN POLICY SIGN IN STORES FOR
HOME DEPOT GIFT DETAILS, j
CARDi
BUV ONLINE PICK-UP IN STORE
Share Your Opinion With Us! Complete AVAILABLE NOW ON HOMEDEPOT,COM.
the brief survey about your store visit CONVENIENT, EASY AND MOST ORDERS
and enter for a chance to win at: READ1' IN LESS THAN 2 HOURS!
�������������������������r•�����������r�
www.homedepot.com/opinion EN T ER F O R A C H A N C E
COMPARTA SU OPINIUN EN UNA BREVE T l7 W IfV A $5, O O O
E N C U E S T A P A R A L A O P O R T U N IDAD DE GANAR. H O M E D E P p T G I F T
CARDi ,
U s�� I� ' Share Your Opinion With Us! Complete
50258 4747g
the brief survey about your store visit
F'a s s w o r d - and enter for a chance to win at:
1347E 47457
www.homedepot.com/opinion
Entries must be entered bv 10/26/2013.
Entrants must be 18 or older to enter. COMPARTA SU OPINION EN UNA BREUE
See complete rules on website. No ENCUESTA PARA LA OPORTUNIDAD OE GANAR.
purchase necessary. U s�r I D -
49054 462'75
P�ssword -
13476 46253
Entries must be entered by 10/26/2013.
Entrants must be 18 or older to enter.
Ses corn�lete rules on website. No
' purchase necessary.
��if"� S�V111�.
r� h+lor� �l�ing;"
2360 WHITE BEAR AVE.
MAPLEWOOD, MN 55109 (651>770-9600
2801 00022 27536 09/29/13 12:16 PM
CASHIER JOYCE - JMP16q8
72055720677$ 2GBARBERRY <A> 17.98
2G BARBERRY .IAPANESE ROSY GLOW CGN
022401100820 INTER. EDGIN <A> 13.97
20' INTERLOCKING BORDER EDGING
08704826q014 6' FRAMED <A>
6' REDWOOD FRAME DIAMOND TRELLIS BRN
2�23,36 q6,72
SUBTOTAL 73.67
SALES TAX 5.61
TOTAL $84.28
CHECK 84.28
XXXf(XXXX2600
AUTH CODE Q08951 TA
I
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2801 22 27536 09/29/2013 1389
RETURN POLICY DEFINITIONS
POLICY I� DAYS POLICY EXPIRES ON
A 1 90 12/28/1013
THE HOME DEPOT RESERVES THE RIGHT TC
LIMIT / DENY RETURNS. PLEASE SEE THE
RE1"URN POLICY SIGN IN STORES FOR ';
DETAILS. i
When you provide a check as payment,
you authorize us to use the inforrnation �
from your check to process a one-time �
Electronic Funds Transfer :EFT> or
draft drawn from your account, or �
process the payment as a check
transaction. Vou also authorize us to
procsss credit adjustments, if
applicable. If your payment is .
returned unpaid, you authorize us to
collect your payment and the Return Fee
amount below bv EFT(s) or draft(s> from
youcp�porate checky�YQUrmakeetheseng a
representations as an authorized
corporate representative.
customeriservice�atsl-888�812�9580ck
ELECTRQNIC CHECK
RETURN FEE AMOUNT $30.00
Merchant ID: 36362801
MERCH TRACE ID 201309291216_2801_22_2�33
CHECK NUMBER
APPROVA�L CODE 1A00310000022181008951
BUY ONLINE PICK-UP IN STORE
AVAILABLE NOW ON HOMEDEPOT.COM.
GOREADYEIN�LESSyTHAN 2�HOURS�ERS
�������������������������������*�,������
ENTER FOR A CHAN�GE
TO W=N A $� . 000
HOME DE�P�O�i GIFT
� Share Your Opinion With Us! Complete
the brief survey about„you+^storea+isit
� �-
I �}�� y H �'����� �� f� � I ����� H �'���� � f� �
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t�� �� �
Bachman's Maplewood Bachm'an's Maplew�otl
26U0 White sear Ave 2600 White Bear Ave
' White Bear, MN 55105 4Jhifie Bsar, MN 55109
551-770-0531 651-770-0531
Store #: 4 Reg #; 1C�6 Store #: 4 Reg #; 10!
Trn #: 33658 Er��p:#1�387� �rrn #: 58957 Emp;#1(19024
Datc : 09/21/2Q13 17;13 [)ate : 09/21/2013 11 :1Q
� Sal� � �� Sale �
��� Sale �** y��� Sale ��*
Customer #00�42001268/1 C.ustomer #t�044�0012F�8/1
Rosane Lof�ren Rnsane Lof�r�n
Salesp�rson: 1038�4 Mary Jo ;3alesperson: 109024 Gretchen
4Q0000294834 PER FIL 1 40G001826959 i'EN HAM 1
1 @ 5,59 5.59 �f 2 � 9.99 15.98 T
On Prnmo; Reg 7.99 (2.40) Wholesale 20% 19.98 (4.00)
40C1003072644 CAL K F 5 ��OUQ01262078 f�AN SWE 1
1 C� 29.99 29.�9 T 2 @ 9.99 15.98 T
�lholes�le 20% 19,98 (4.00)
Subtota1 35,58 ��UU00255044f3 ECH P M 1
Tax @ 6.875 MN 2.45 1 � 9,99 7.99 fi '
Tax @ .25% Trn 0,09 4�holesale 10% 9.99 (2.00j
-------------- 1�000Q0294834 PER FTL 1
Total 38.12 1 � 5.59 4.47 T ,
_.___----------------------�._._,.____-----.__ (ln Pramo: Reg 7.9� (�.40j '
Total Units Sold: 2 Wholesale ?0� 5.59 (1 .12) '
Cash 4�.12 754381d28244 AGA 6 F 7
Due Customer (2,00) 1 C� 8.99 7.19 T
You saved a to�tal of: $2.40 Wholesale 20� 8.99 (1.80)
;�54381057107 Gh AN IW1
TNAMK YOl! FOR SHOPPING AT BACNMAN'S! 1 � 12.9� 10.39 T
Visit our web site at wa�w.bach�rians.com Wholesa'I� 20� 12.�9 {2.60)
400001617458 SED A F 1
PLEASE SAVE YOUR RECEIPT 3 C� 6.99 16.78 7
Far c�nvenient returns ar excl��anges, Whalesale 2096 20.97 (4.19)
Complete d�tails on back �fi recai�t. �26535A04060 PAN NQR 5 �,
1 C� 29.99 23.�99 T
wha1asale 2.0% 29.9� (6.OQ)
�+00003072fi44 CAL K F 5
1 C� 29.99 23.99 T
Wholesale 20� 29,99 (5.00)
�0001931370Q GRQN 50IL
3 � C �.g9 � 9.5$� T
4��holesal� 20� 11.97 (2.39}
00004106033658103874 Tax�(�ta6,875 MN 1�9.37
iax � .25% Trn 0.3�
--------------
Total 146.05
"fotal Units S�ld: 16
{:heck 146.05
� ��659 �o
t:�,, ...,....a ., .w,..a.�� „f. r�a� �n
..,...�. _
'y � 1
-- • -- ------�-- � �f �� .1 � ���'� ,r ► I '1 L l
� • L I N DER S r�.., �F.. �,� f./�/`f, /
e..fl1[3''lel�.to�x f.G i1('.l.X�Cl.lf�l��I.rlr2+fi.'�
THE GARDEN EXPERTS
LINDER9.CQM I 651- 488-1927
���'��� ����t��' Bachma�'s ��aplewaod
270 Larpenteur Ave W 2600 White Bear A,ve
' St. Paul, MN 55113 White sear, t�N 55109
Ticket #005-1259326 User�PEIFl 65i-770-0531
Station�502 Sales Rep PEIF1 ,�tore #: 4 Re� #; 107
9/26/2013 1U�48;52 AM 'frn #: n02.3B Enip:#107132
(laf� : t�9/291�013 11:5Fi
�K S�l e *
----------------------------------------
Item Qtv Price l�otal 'K�� �ale ���
Description i:ustamer #00442001268/1
------------------------------------------- f7asane Lofgren
1702001594 1 17.99 77.gg `.�a1�spF�r�yon; 147132 Gayle
Hvdran�ea 'Twist-n-Shout' #2 -�r�4��105]107 uR AN TW1
You Saved� 12.00 1 @ 9,09 9.09 T
------_----- (in Promo: Reg 12.95 (3.90)
Subtotal 77,99 4000��U461939 AS-IS
Tax 1.37 1 � 22.50 22.50 T
Total ------`19.36 ;�uhtotal 31.59
---�-_------ �iax � 6.875 MN 2,17
Tender�
------------ T�x @ .25% Trn 0.08
CASH 2O.00 �fotal 33.84
Chan9e (CASH) -0.64
---------------
�fotal �nits Salii: 1
Number of items purchased�l L'heck 33.84
Total Savin9s_ 12.00 E_�-�
`tou sa�ad a total of: �3.90
fHANK YOU FbR SNOPPTNG AT BACHP�AN'S! .
* 3 0 2 3 6 9 4 4 9 9 0 8 * V�isit oi.r web site at wwu�.bachmans.com
Pl_�AS� SAVE YOUR RECEIPT �
For conver�iet�t returns or exchanges,
Cc7mplete d�tGi1� on back af rsceipt,
00004107060238107132
.s
Stillwater Medical Group
700 Wildwood Rd
MAHTOMEDI,MN 55115-1852
� Name: LOFGREN,ROSANNE M Patient Name: LOFGREN,ROSANNE M
VI� . 3070054 Medical Record #� 50107799
iotal' 09/16/2013 Encounter Form #: n/a
69�16�13
I�r �; �3 �PPr� Payment Source Reference
�; Ofllll� Batchp, TNE M 3 5 . 0 0 Credi t Card 19 8 6
Customer Copv
THANK YOU FOR VOUR BUSINESS�
Total 35 . 00
Thank you for your payment today, please save receipt for your records .
Any remaining balances from this visit will be due 30 days from receipt of your
statement. For questions, please call our Business Office at 651-439-6528 or
1-800-598-2544 .