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Poole NOTIC� OF CLAIM I'ORM to the City of Saint Paul, Minnesota Miniiesotn Stnte Statute 466.05 stn/es drnl "...evriy persuiz...who clnim.s dunrages./rrnn mty�mulicipcdih�....rl�ul/cnrese In]�e presenter!1n[he goi�erning borfy of d1e n�unicipality H�ithii2 1<SO duys tifter�l�e a/leged loss or injury is cliscovered n notice stnting tMe tinte,pince,c�nd �irc�wnsta�rces tlrereo%clrrd�he amount q/'cartpensntinn or nther relief demnnded." 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 dependin�on the natum of your claim. This ti►rm must be signed,and both pages completed. If somelhing does not apply,write`N/A'. SEND COMPLET�D FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name � Middle Initial�Last N�me / � VED C��m��ttny c�r�iusiiiels "•Tanie - — ��_�O�J --� Are You an Insurance Company? Yes/N�f.Yes, Claim Number? StreetAddress � �.. �� '�1�`Y CLERK City r State l � �` V Zip Code �� /� Daytime Phone �� ell Phone (�)sz��`��g Telephone ( ) - Date of Accident/Injury or Date Discovered ��c�� Time�am/p� ��—�� no �crr��- � � � r�u � �� r�P�� Please state, in detail, what occurred (happened), and why you are submitting a claim. Please i�ate why or how you feel t e City of Saint Paul or its employees are involved and/o�esponsible for your damages.Td'iL� �t�� " (.-� S �(,v' �- ' �' v r� - 7 - `� " �`v v,.�-. �,-, � 5 � v� a � � n � �G�-- `e� � t,� / - �, �-. �� 1��`� �t�`�� ` �`"' y�. ,_ G �G�/`�ti� �S G � 2 /� � °� � P1�< c e t x e t at most close� e resent the reason for comp �ng this form' ` l �� -�� ,`L/p�,1� ❑ My vehicle was damaged in an accident ❑ My vehicle w�►s damaged durmg a tow ❑ My vehicle was damaged by a pothole or condition pf the street ❑ My vehicle was,damaged by a plow � ��q�� ; ❑ My vehicle was wrongtully toweci and/or tickeceu ❑ 1 wa5 injured vn City pru�rty- -�� i �-9tl�er type of property damage—please specify �w�� v�C>U�i % /�r Y ' ❑ Other type of injury—please specify � 'e'�� In order to process your claim you need to include copies of all apnlicable document�� ,��U�.�I i 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 r $500.00; or the actual bills and/or receipts for the repairs �� 3 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 JC and/or receipts for the repairs; detailed list of�lamaged 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 I+ailure to complete and return both pa�es will result in delay in the handling of your claim. All Claims.—please comnlete this section Were there witnesses to the incident'? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? �� No Unknown / (cir� ) If yes, wha[department or agency? Case#or report# ( � ` �}� �'Od� 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. �S � �t.r� �— Please indicate the amo mt ou are seel:in in compensation or what you would like the City to do to resolve this claim to you�rr satisfaction.� �6 -a b �,� ��1�e I- � � �S�- � c� /�t S �r _,� /�i�� r� �,` �' ;� r v, Vehicie Claims—Qlease�uij�plete tf�is sectia�i � check box if this section does not annlv 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 jur�Claims—please complete this section ❑ check box if this section does not apply How were you injured? What part(s) of your body were injured? Have you sought medical treatment? Yes o Planning to Seek Treatment (circle) � When did you receive treatmetit? (provide date(s)) Name of Medical Provider(sl: Address Telephone Did you miss work as a re5ult of your injury? Yes When did you miss work? (provide date(s)) r�{,�� ,�;.,,-�.rrg.oT��: - -- - _ �_ _ --- -- Address Telephone , ,,e Lheck here if you are attaching more pages to this claim form. Number of additional pages �. � By signing this form,you a;e stating t/zat ull 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 prosecutiofi. Date form was completed L 0 �' ' � ' J� Print the Name of the Person who Completed this Form: �✓ t M i ��v '� Signature of Pers�n Making the Claim: Revised February 201 1 , � � PAGE 1 OF 1 OAKD 30281862 CAS�ER: SPECIAL ORnER CONTx�CT IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIlIIIIIII PLEASE GUEST COPY GUES'f NAME-ADDRESS-Pf-IONE STORE#3022 OAKD PHONE: (651)777-0048 La, La STAPLE 3205 Hadley Avenue North FAX: (65 I)779-6011 i La sc Oakdale,MN 55128 woodbury, r�N ssizs RECEIPT THANK YOU! Ph: (651) ��-�� ESTIMATED ARRIVAL DATE i �D�• NOT BINDING ON MENARD,INC. l�� BASED ON PROMISES BY OTHERS 1 O�2 9�13 SOLD BY ORDER DATE ' BEN T. 10/15/13 EMAIL: JOB DESC: TY ORDERED DESCRIPTION SKU UNIT PRICE EXTENDED PR10E _ — - �2 EACF'i �4" WA rRFO12D .0�2 SAND 146-6326 5.69 68.28 � 1 � I This is a quote valid today.This quote becomes an order upon payment and a valid Menards receipt for this order is attached. READ THIS CONTRACT CAREFULLY.The tertns and conditions set forth in this document are a complete and final expression of the patties.Any and all claims under this contract must be brought within one year of purchase. SLJ$-'I'QTAI,: 6 8.2 8 "Custom made"special order merchandise purchased from Menards is NON-REFUNllABLE."Noo-custom made" Special order product may be refunded at Menards sole discretion�vith a 25%restocking fee.Purchaser is responsible SHIPPING: 0.0 0 for providing to Menards all measurements,sizes,and colors stated above.Purchaser's exclusive remedy,if any product is defecdve or fails to conform to the terms of the contract,is replacement of the product.All defects and nmrconfomiities PRE-TAX TOTAL: 6 8 .2 8 must be reported to Menards within 3 days of receiving the product.Purchaser understands that all product is sold"AS IS," and ihe manufacturer's warranty,if any,is conirolling.biENARDS MAKFS NO\VARRANTIES,EXPRESS OR VENDOR:RP BUILDING PRODUCTS LTD IMPLIED AS TO THE MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OF THE PRODUCT. There are no reprosentaGOns that the products listed herein meet local,state,or feder�l code requirements.Menards liability Far the most accurate and up-to-date stahis shall not exceed the purchase price of the products sold.MENARDS SHALL NOT BE LIABLE FOR A'�Y SPECIAL, of your order,please visit: INCIDENTAL,OR CONSEQUENTIAL DAMAGES.Menards agrees to email Purchaser when the product is available for pick-up.If Purchaser fails to provide an email address,it is Purchaser's responsibility ro�heck the status of the order W W W�menards�COm by visiting Menards.com.If Purchaser refuses or fails to pick up the product wiUiin 15 days'from d�e date of its availability, Menards may liquidate the product and shall be entiUed to a 25%restocking fee.Menards may withhold any payment received as partial safisfaction.Purchaser agrees that Menards is not liable if the vendor,which supplies the product on this If this is a partial pickup,please verify all contract,fails to perform.Purchaser agrees that any and all controversies or claims arising out of or relating to this contract, or the breach thereof,shall be settled by binding arbitration administered by the American Arbitration Association quantities/items being signed for. Menards is underitsapplicableConsumerorCommercialArbitralionRules. not respOnsible for shol'tages after leaving tlte YOUR PURCHASE OF THE PRODUCT ON THIS CONTRACT CONSTITUTES YOUR yard. AGREEMENT TO ALL TE�S AND CONDITIONS STATED ABOVE. IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII y - • PICKING LIST - GUE;ST COPY S'i'ORE#3022 OAKD PHONE: (651)77"7-0048 CASHIER - PRESS RECALI.. TRANS OAKD 60158 3205 Hadley Avenue North FAX: (C51)779-601 1 AND SCAN BARCODE __> III'IIIIIIIIIIIIIIII�I�IIIIIIII IIII (:)akdale, MN 55128 — CASHIER' PAGE 1 OF 1 Gl�E-��N.AMF- ADDRESS- PHONE � Poole, Ben Pl,EASE STAPLE - SOLD BY: STEVE D. DATE: 10/7.5/13 � RFCEIPT HERE. Ph: (6��7.) 174-3663 JOF� 1)1�;SC:: �.,. ___ -- - — �� ' � I1 11" DESCRIPTION SKU NUMBER UNI'T PRIC'li GXTENDED PRICF 1 NOSO E-660 HALF MOON 4-PNL PH 32X80 RH DB 414-2621 169.00 169.00 1 _ _ _ �'�I��e��' ��'$�� ,�BZ:� ��-f��,f��'��. Dl1T'�; -- - - PLEASE PICK UP ALL MERCHANDISE TODAY. �I'H:ANK YOL1. I�his is a yuote valid today.Upon payment this quote becomes a yard pickin�list sul�ject to the terms and coi�ditions bclow. Quantiues listcd ohuve may excead quantities available for immediatc pick-up.Product is not held 1br a specific guest,but�nstead is available to the buying public on a I'ir;t a�mc,I'irat scrvc hasis.Please pickup all purdiases made on this picking list immediately.Fail�re to pick up products on diis pickmg list today will result in additiun;�l charre i�i y��u if.c�n ihc day of pick up,the retail pricc ot�the products are higher than on the day purchased.Menards liability to you is hmrted to refundmg your oii,�in:�l�iurchasr prirc Ii�r anY pi'��duct not picked up. Gucst Instructions: 1. Take this picking list to a cashier to pa,y for the merchandise. 2. Enter the outside yard to pick up your merchandise. (All vehicles are subject to inspection.) PIZ E-`f AX "I'O'fn f.: 16 9.0 0 3. I.oad,your merchandise. (Menards Team Members will gladly help you load yom•materials bul cannot be held liable for damage to your vehicle.) ��'hcn exiting the yard,present this list to the Gate Guard. (The Gate Guard will record the items you are taking with you.) 5. Sign the Gate Guard's signature pad verifying you've received the merchandise. Our insurance does not allow us tu tie down or secure your load,trunk lid,etc. [or your convenience,we supply twine,but you will have to decide whether or not your load is secure and if the twine supplied is strong enough. If you do not believe the iwine will suftice,stronger material can hc p�nchascd insidc�he storc. READ THE TERMS AND CONDITIONS CAREFULLY. All returns are subject to Menards'posted return policy. In consideration fiir Menards low prices you agree that il'any merchandise purchased by you is defec[ive,Menards will agree to�xchange the merchandise or refund the purch:ise price based im the form of original payment. Ynu agroc that there shall he no other remedy available to you. If there is a w6n�anty provided by the manufacturer,that wananty shall gu��crn yow rights and Menards shall bc,elling the product"AS IS." Oral statements do not constitute wan•anties,and are not a part of[his conh�act. The guest agrees to inspeci all mcrchandise prior to installing or using if. UNDER NO CIRCLIMSTANCES SHALL MENARDS BE LIABLE FOR ANY SPECIAL,INCIDENTAL,OR CONSEQI!ENTIAI.DAMAGES. MI�;NARDti MAKF,S NO WARRANTIES,EXPRESS OR IMPLIED,AS TO MERCHANTABILITY OR FITNESti FOR A PAK7'1CliLAR PURPOSE OF THE MF;RCHANDISE. Any controversy or claim arising out of or relating to this contract,or the breach thereof,shall be settled by arhitratiun administered by the American Arbitration Association under its applicable Consumer or Commercial Arbitration Rules,and judgments on the award rendered by the arbitrator(s)may Ue entered in any court having jurisdiction thereof. The guest agrees to these terms and conditions through purchase of inerchandise containe�i on this document. TH[s Is NOT A uECEIPT GATE GUARn - SCAN HERE __> IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII � � I I � � ��I ,�..�--'�..-��°".�-�`"��I • �� : : �. k .... # �".: .. � 1 � � : �� '�Fi �� . . .. ��., ,.�,/i' . �� .. . . -��,.�. � � � � �� ,� � � � t �.��,�` � ,�� , �" ti �,� �= � - .M � ..,,..,:�•� • ....:'' � . . �, �� ., � ��,_. . �. .; , �. � ��., _ y �� k �z., f� �a�yi C .. 'u �� ° �„, '. ,:,,.:"°� Z � , ��. `t��:." �"F '�.� '�` ��'- :�� ;�.>. �� :; . � �,� I '�� . � `�;,,. ��` I� .�:" - � P�� i ��. �.; S � i��:� :,...S � " �� . . . " � I ��; . � . .. . 1 r;.' . � .. .. . . . .. .. ., '�' '�,�f.�..: . ..� :.',':> �.f� - . . . + � ��;*�J � � I k �'. � 31 ri` � � flis� . :,n, �{ . . � � � r l '� _ �� ;� T: , '��, a � �'� - � � � � � . ' . •kj ,, . + �„� . y ti..� +y ' ''+ � ; I I i I � � i s � � � 1 � �