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� , � 1 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states rhat"...every person...wiu�claims damages f rom any municipality...shall cause tn be presented tn the governing body qf the municipality within 180 days after the alleged loss nr injury is discovered a notice stating the nme,piace,aru circumstances therenf,and the amount of'compensation or nther relief demanded." Please com�►lete 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 e�lain 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� c�S � Middle Initial�Last Name ✓ ��'�`''�I�''` � Q�r���p �_ _. Company or Business Name ��T ' � 20�3 uVi lv Are You an Insurance Company? Yes/� If Yes,Claim Number? E�K Street Address l� � �i�f Y �.r'�1 , � �'1/• City �d�h'� �c��il State /"1•�'� Zip Code ���U ( Daytime Phone(_} - Cell Phone( �� �_�Evening Telephone(_) - Date of Accident/Injury or Date Discovered �"�/ ` � ��� Time�,.��/pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the ity of Saint Paul or its e loyees are involved andlor responsible for your damages. �, �-,e W ' P 0 0�. c�r r,' v �^ o+,• � � 4 yt � ' y. f A � � � ' . "7 . , � 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 �S,'�VIy vehicle was damaged by a pothole or ondition of the stre ❑My vehicle was damaged by a plow ❑My 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 you need to include copies of all auplicable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your ctaim. 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 �er prope�ama e claims:two repair estimates if the damage exceeds$500.00;or th actual bills ��nd/or receipts for the repairs•detaLed hst of damaged items O In' c ai :medical bills,receipts hotographs are alwa s we come to ocument and support your claim but will not be returne Page 1 of 2—Please complete and return both pages of Claim Form y — � Failure to complete and retum both pages will result in delay in the handling of your claim. All Claims—nlease comnlete this section Were there wimesses to the incident? Yes N� Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes No 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, ame of par or facilitx, close�s`landmar ,etc�./ Please be as detailed as possible./ If nec�e,j�ary,attac a diagram. �or^f�j � � /dhe �s`T �X hGrTein /41re. .tLt�_�qo►-'t{� O /- ,, v ��tPr Please indicate the amount you are s�king in compensation or what you would like the City to do to resolve this claim to your satisfaction. �G�� L tL i Vehicle Claims— lease com lete this section ❑check box if this secdon dces not a 1 Your Vehicle: Year �D Make Fa•-d Model �o�ti S �✓ -�T License Plate Number�l Sl� L�� � State .�i�Color Tdr� Registered Owner T� S�'P w P�'� Driver of Vehicle �o S�' w Area Damaged � �- S i ao .�r��� r 1.�s' �J H� P � , City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—please comnlete ttus secNon l�check box if this secdon dces not annlv 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 wor result of your injury? Yes No When did yo ss work? (provide date(s)) Name our Employer: ress Telephone �Check here if you are attaclung more pages to this claim form. Number of additional pages�. By signing this form,you are staxing 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 �o - ��-- a��3 Print the Name of the Person who Completed this Form: �Ule,o! . 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J05EPH Q 5IEI�Ri T HA�1K VOU C115i0MER COPV � . � . � • • � � �� �,�;��,.� ,,� � �� . �,, Bill To Joe Siewert Plate 418CZH 963 Bayard Ave W Description Gold 2002 St. Paul, MN 55102 Make Ford Focus USA Engine 4-121 2.OL DOHC Odometer 83,357 Phone (651) 592-8885 VIN iFAFP36382W357876 PO # N/A Work Order# 0000031068 Invoice Date Apr 19 2013 Invoice# 0000025873 Appointment Apr 19 2013 7:33 am Svc Advisor Jacobs, Scott Promised Apr 19 2013 9:33 am Technician Degayner,Timothy Problems Resolved Vehicle Hit Pot Hole Customer stated he hit a pot hole and blew out both the d iver side tires. Inspect and advise as needed. Af�er initiai inspection, found both the left tires and rims are damaged and need to be replaced. Also noted during the inspection, the front sway bar links are loose and the rear shocks are leaking. While under the vehicle, noted there is a oil leak that is coming from the valve cover gasket. Labor To Diagnose Prob(em $41.09 * GNork Performed By: Degayner, Timothy Sub $41.09 Servic�s Performed � Milage In Mileage Out Sub $0.00 Wheel Alignment Inciudes alignment and reference on front and rear wheels. Extra charges may apply for shimming rear wheeis if applicable, and on some front end adjustments. Noted during the service, the (eft inner tie rod end is bent and needs to k�e replaced. Labor ��g 95 * Work Performed By: Degayner, Timothy Sub $79.95 Instail &Balance 2 Tires Includes installation of tires onto rims, cleaning of rims, installation of new valve stem and computer balance of tires. 835.418 - Valve Stem 2.00 Units $0.98 / Unit $1.96 M 38635 - 195/60r15 Uni Tp Tour Tires 2.00 Units $79.65 / Unit $159.30 MT ALLOY - Wheei Weight 4.00 Units $1.47 /Unit $5.88 M Used Rim 2.00 Units $150.00 / Unit $300.00 M Labor $25.00 * Work Performed By: Degayner,Timothy Sub $492.14 Left Tie Rvd End -Inner- Replace ; EV419 -TIE ROD END 1.00 Units $43.44 / Unit $43.44 M Labor $102.73 * Work Performed By: Degayner, Timothy Sub $146.17 _t?eferred Work Rear Shocks- Repiace Replace Valve Cover Gasket 910 Randolph Avenue St Paul Minnesota 55102 Phone: (651) 298-0956 Fax: (651) 298-0886 Email: scott@stpaulauto.net Invoice Totals Total Labor $248•7� Total Parts $510.58 Total Before Taxes &Miscellaneous Charges $759.35 (*) Shop supplies include charges for cleaners, small hardware items, chemicals, $19.90 and shop towels used in quantities too small to itemize. (T) Tire Disposal Charge $3.00 Each $6.00 M (M) Minnesota State Sales Tax 7.625 % Totals $824.64 Invoice Comments THANK YOU! We appreciate your business. Siewert, Joe paid $824.64 by Discover. 910 Randolph Avenue St Paul Minnesota 55102 Phone: (651) 298-0956 Fax: (651) 298-0886 Email: scott@stpaulauto.net ,i rHU��►vivmv�ivc , ` ' 910 RANDOLPH AVE ST PAUL MN 55102 651-298-0956 Name Address _ _ _ _ Telephone Vehicle(VIN) License Techniaian Mlleage _ Time Printed 4/18/13 6:67 PM Ford : Focus : 2002-04 : Wagon setore Measurernenrs t.�t FroM Right F►ak � t t � � � � �, �� '� -- �f�i�� � � FroM �X� � �� Toe � ��• Tw 01�Tce x�� .'C9�� �BerAlleed Left Rear RiyM Rear � � � ` � � Cali�lf '�A111b8� �' � ' t� �� Tce �� Toe Talal Toe 1 � llrust Angle CurreM Measurerrients L�t F�aN Ripht Front � � �:� � � � �� �' ,� �� (�SfQ CiSIR �� �� �t�� Tafal Tae T p�p nn�sa fl Left Rear RIyM Rear � � � � "" � Rsar T 1�1� ��y �� �r Tatb Toe 1 � ' � TMust l4tgle � �'h� �te�rint��rh�el is curr�ntCy �eve�. �