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Ahmed (2) lnstruct�o�-�s far Filine� tVotice of Clain� ta City af Saint Paul� ;11in,��s�:� �t�ta St�tute 466.05 NOTICE OF CLAIM...!E)very person...who claims damages from any m:�ni,:ip�lit��...sn�l� cause to be presented to the goveming body of the municipa/ity within 180 days afte� the � alleged/,�ss or inju�y rs discovered a notice stating the time, place, and ciicumstances thereof, and the amount of compensation oi other relief demanded Please complete tfiis form in its entirety by typing or printing your answer to each question in tf�e space provided. If additional space is needed, please attach additional sheets. � RECEIVED PLEASE RETURN THIS Office of City Clerk COMPLETED FORM TO: 170 City Hall GEC 16 2013 15 W ICellogg Blvd CITY CLERK St Paul MN 55102 Your Name: ����5 {�hn/}P[� _ Street Address � 2 ` _ _, City: __����.1�� State: � _cLLL� � Zip Code: � Daytime Telephone: (ZL�1 �Z(—� �� Evening Telephone: ( ► Date of Accident or Incident: (}� �6 �Day of Weel<: Time: am or pm (circte onel , Plaase stata, in detail, wl�at occurred and the circumstances surrounding the event. Indicate how the City of Sci�t Fau! is involved, and why you feel the City is responsible. Y �'`�v'�" V ' ' IM � W , ,v �� • - \ h� -c�- v ` i:fe ay o , , � i kY�S da��d • �I,��r�-�� �� (ea�.1x�C�-'� l�� �- 1��.ac�.s�..�ir-i►` i � Please indicate ur reaso for completing this form: SC1�ati 1 .so6 v-�. 50 t.ue._ lil�(�-�{.� �r '�v� .So��v�-t �l ��-I,�a.c� le.�- , � ;".,�I. (.--1 Vehicle accident C_I Other property damage {please rovide sp�fics t5elow � ��� �Vehicle was towed ; !;,: �Vehicle damaged ❑ Other injury to person (please provide specifics below) , '!� ❑ Slipped and fell on City property �'` ,,;, Please provide the names and telephone numbers of any City employees involved in this ' � ;: ; incident/accident and t�ow tf�ey were involved: � � ` v ,� �c� � �, ; v a ,� ` ^wbv. (over) . If your vehicle vvas involved, please complete the following; �S(Il�/� ' I . Year, make, and mociel: �ji�(�� �j ne �(� o�R3 License Plate Number: =o3�-f���'f Exient and area damaged: ��Yp�ySj�je ViPW YV1(YY�✓ brc;ken ��)ho,n �ivhit�he -�u�a'J �n� -1�,ke,n -�ta i►�'1��d ��� Was a City vehicle involved in this accident/inci ent? Yes No � (circle onel If yes, please complete the following: Type of vehicle Year, make, and model Color of vehicle License Plate Number: - Description of vehicle Location of accident/incident (please provide specifics sucfi as street address, intersection, cross streets, park name, facility name, etc.): � � O t . 0.hC, �.1 Yl Cc� Yl �u�-�l r Please draw or attach a diagram if applicable: . j?�c� c�-� c�+�2;;�e� d viv� S�de vi e� ��►n�� at�drerJl - A��.s� atlac�ed�• �- C�C�Sfiima�--'�� v�?�G�Li J�S� � �e�iY ��P waS �o-f- � � C�I�e- v�-�.i vY'�r . S�-� i f- �IC�,S c�x-�1d � ��"�fi v'�`��--.�0� -}L�2- 1� �;�,',�` _ ,� . � w� �� (��`�it,� �unr� � • �� �ivrt-��1 I w�.�ov�)d Lt>f -�e- ��- dvi��s+c;1e�,au�w� � � � ` �n ve,�.�,i:c�c-1�- �'�, '�ctv�'� �� �S c,�h���y � Prea�pecif he nature and extent of the compensation or other relief you are requesting. Plea e� ' �� attach copies of any bills, receipts, tici<ets, or other documents to support your claim. If you are �h . claiming damage to a vel�icle, please submit two estimates. 2.C� , •6 a , , v� v�t - Were there witnesses to this accident/incident? Yes No circle one) If yes, please give the names, addresses, and telephone numbers of the v��itnesses: � Were the police called? Yes No (circle one) If yes, �vhat department or agency? Police report number: Please print the name of the ���lS ` I_� person completing this form: I�YI Please sign your name: � ` r : Date form signed: 1M� �� ��� Risk Mgmt Division - Revised 1-30-01 �`• , :.r�;ct��: ��� �-��✓� � State of Minnesota Ramsey District Court CITY OF SAINT PAUL PARKING CITATION cnation No. 620901249029 Case No.: SL Paul Police Department Vshicis Liconce Numb�r: O�ZRY sut�:IA USA Yebl¢Is VIN: Make:PONTiqC Mod�l:NDT IN LIST Color;SILVER Tab Month: TYP��PASSVEH Tab V�ar: Date ol Otlsnee 8l16l2p13 Time o►Otlsnse 07:13 St�tutstOrd ORsns� 769.34.1(a)(1d)PARK WHERE SIGNS pRdHiE1T ORmae Loc�tion: SYNDICATE ST S Intersectlnp Strset:LINCOLN AV 2nd Cross Stnet GOODRICH AV ORens�City: St.Paul M�ter Numb�r: Permk Zone� Chalk In: ChdM Out: Sipns Vie: Unit:952 ParAsd: (HH:MM) TimsZons Oficer t:PEO L.Ayers OTc�r Numbec y7510 oRicer 2: . ORicer Number�. Report defecUve meters by noon the next business day Call(657)200-�778 To pay your fine by credlt card,wait 5 business days and then call (851)288-Y202 I/citsd fo-r N proof a�Insurancs or No Drivero Lica�ae in Poeseasion,Proof of Insurance andlor Drivers Litenne should be ahown in one of the Violeticns Bureau location9 listed below within � .�J�.Vi� �V� �D��(� �wt��G� � � �,��.,`2 �2��� �c:�✓� 0 0 0 N � N , � '� � � � R� � ,�y J � �* 11. w LL V � O O N � � � � O � � O � C�° °Cl� ° � O � .�i (U � — � Z � � cfl ea s; t� c� v> > _ � � Q 1 lil � v �J N � � � � o m i/i w U � � � ° c`u � �> � � m � � � � � � .� . . U cU c J >, � L> W c-� c � ccncccco � > m �'= � O C CV t�G N C , � � C ^ O<Y C t c;O I^'� O Q �.c� ("J � ��07 �O � Z G G W r- C t� � _ � p � - Q ^ N� G _ � �.f; F N � � - Z�I..C)Z � U� Z 2 Z I � C C ' _ Q�C.^ J` C - - � (f,f . �^� T-'C�i� � J C W� m '/� -Q.-N W � O y' T "' C d u";\ C^. .- � - � ��� CG�S." �¢ h- .:V: F-V\ ¢ � Q, � C C!7 m � � W ` Z } . � ^ � C/'J l.� Z . �' 3 J Z J L Z � Q � � r-i � x�c=¢¢ � N .. 4 � ¢ � ¢O¢S S Q J � '�� C S ^ Q F-G_:C_;VJ � } � '� . �. .� � � � L J � � � � � O U � � � U U V7 Q W J J r� a �� � E E I � � r- � c0 N — N ' O � O � � > . � N Z (n , � N > �p t� C O � � �- Q � � � „_, � � C � I (7� � o O � � � > � N �' N � � N L cU � } � '� � V r? �"� N � � U Q � O � -C L "p Q C'"'O � '� � I'� (U ~ �O � � N (U � O (p � � � Z � � = W � � � .0 � .� o � F- � � O � � �, °'� cvi ° � °- a � � � � ° Q � �LY oa � � c Q W � o E � U � -�'a a�i > c�o � ° @ � O L� +� j.= v� � �n � .� c� a �"- a� � � � � �; � � � � � � � � c� °�' a �o .� � � � a N N = >,c � � ._ c C/� � o � a � � .3 E in -`°a o o � � in - ��� � �,� ' ��� s�c� v� v��v�v�r - � � �3.�. r - �� � G�oss�x�Ce.v, " � `� , _ . ,. . �� Jr h j{ .� % �- \�:i7:r�� '-id�. _ ' • / �.-Jf �a?��� �rf J —'T„stirT . `t ' Ph� -taken @ Ivv��� l�-. j i �II ____--- Date: 08/21/2013 ABRA MN Midway REPAIR ORDER AUi�I B00��C 6LA.SS 1190 University Ave W RO #: 24084 Saint Paul, MN 55104 651 645-1563, 651) 641-6129 (fax) Est: Pat Kearin 03 PONT BONNE ILLE SE AMENA AHMED Color: SILVER Y Customer Pay 1290 GRAND AVE #202 Type: PC 4D SED Adjustor: ST PAUL, MN 55105 VIN: 1G2HX54K9341 01 41 7 Phone: Home: 217-721-3979 xOWAIS Prod Date: Plate: IA 034-ZRY Claim #: * Deductible: 0 Work: Mileage: 555555 Loss Type: Fax: 217-721-3979 Engine: 6-3.8L-FI P=Who Pa s? I=Insurance,C=Customer Qty Type Description Part# Amount Sup Labor Op Labor Paint P # Units Units 1 Parts Glass FRONT DOOR LT Glass w/o heated 12482403 155.99 Body Repl 0.2 I glass Sublet FRONT DOOR Freight overnight 25.00 Body Subl I shipping SubTotal 191.79 Taxes 11.89 Grand Total 203.68 Due from Insurance ' Due from Customer Sub-Total 191.79 Sub-Total 0.00 Tax 11.89 I Tax � 0.�0 --------- --------- Total 203.68 Total 0.00 Total Amount 203.68 i i l� �lo� c��t� -�nc� -� �in�r� cc�, z --� �Iar-� a�c� 2 �;;�,�,,� �a..c�v�a� �i�t�� �� � . i►^�� �1 ��e. �S �`J � ----� -fiWc> �}ir�l o�o� � °�-�.�'��acav�� -N� �c�,sS,C2) .�e�r� P�i�n�+�-�� �.�� -�-- �n�t� ��wo� �a�+. v�;lE. �-k- w%1-� .1�,-8���1 'S S �-i�rn . 1�.� d�tL Ino�vz �� � ���e d�e�i�e �-� � �,�`,�— I�.�� ►rvt� , h��...r �t,v�d� �ca�1� I�d�� a IoccC�-� �o� �ca� ���=l�i�e�rs S�� ��s , v�i1�Q� ' �L�� REPAIR ORDER�� #10 08/21/2013 04:26:3 PM RO#2 8 ) 1� �"�"�AB A C�9e 1 �% Gcv�O� ��� �.�I��}---- �,v�2 wt}�av-y'` -� ti,�.�wn►'� c7v�-� (n; �� . _ �`�--� - --� AY 5290 ABWAY �� ABW 1190 University Avenue St Paul, MN 55104 (651) 645-1563 AUG 21, 2013 4:23 PM REFERENCE 24084 AMEX XXXX 1008 TRANSACTION: 487170043 AUTHORIZATION: 522142 AMOUNT: $203.68 � � � amena m ahmed I AGREE TO PAY THE ABOVE AMOUNT ACCORDING TO THE CARD ISSUER AGREEMENT (N`,ER�i�AIvTT AGREEMENT IF CREDIT VOUCHER) - Thank you -