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Obee � �/�� (.c.�t _ . ' � _ NOTICE OF CLAIM FORM to the City of Saint Paul, innesota tilin�resotcr Stnte Sta�trte 466.0�s�ntes�hn� " ...ei�ery peisa�...rt/ro clurms dnnm es ronr � ��'`" �Q�~/ g f a ry n�t�rricipaliry...shall cai�se to he presented ru�hc ;orcrnin,;horfr o/'tlre nurnicipn(rt��tivithrn l80 days qfter[he alle;ed loss a�ir ju�y is drscovered n no�ice stnring rhe time.pince, nnd crrcirmstnitces tlrereqf, and the crmorrnt of compcnsation or•other re(ief demanded.r_s�^ ��}' ��! ,�7J! 1U o� Please con�plete this form in its entirety by cleai-ly typing or printing your answer to ea�uestion. If rf�or�space is needed,attach additional sheets. Please note that you may or may not be contacted by telephone to discuss your claim ,�. •'��Q/ circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation beingU'�'� requested. 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 �/��'�I C Middle Initial� Last Name �� R�(;��[� Company or Business Naine, if applicable ��j �,� ��1� Street Address �2 `� -(��(�U,� frv� , �.�� K � f '�,...� ,.� City ST� �ACwt� State � N Zip Code �� Daytime Telephone ( �0 L) �' !�� S� �.1.� Evening Telephone (�_) �"�(D— .I.�1 � C,�-�l Date of Accident/ Injury or Date Discovered 1,Z'�� 3 Time �� a�n /�(circle) Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible. b �o l.D � . S � �1- S o Z 3 , W�1�K � ��f.t�-t2D 1,�,� -n�-�� _ S - � ►r�l� W� LD�SE , �g�:l � , �� l, -}� �1� � �S' T� 'b�� 5��+-� -r� �t �� . ��A��L�I 6�b o-� �11n R-tL-I.�ll., 0'�1]� �� t"�� fio�� t2��'�D "t'd vJ f�� oNs �-� , r�t,s� o � �t° vJ � Please check the box(es) that most closely represent the reason for completing this forn1: ❑ Vehicle was damaged in an accident �'Vehicle was damaged during a tow ❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow ❑ Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property ❑ Otl�er type of property damage—please specify_ ❑ Other type of injury—please specify ❑ Other type not listed—please specify I ln order to process your claim you need to include c�opies of all applicable documents. This is a general guideline of what should be submitted with a claim fQrm, but it is not all inclusive. You inay be asked to provide additional infonnation depending on your claim. � Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the actual bills and/or recei�Z� for the re=»air,� � Towing claims: legible copies of any tickets issued and copies of the impound lot receipts O Other property damage: repair estimates, detailed list of damaged iteins O Injury claims: medical bills, receipts O Photographs can be provided but will not be returned. Page 1 of 2 — Please complete and return both pages of Claim Form Failure to provide a completed claim form will result in delays in processing. i � Notice of Claim Form, City of Saint Paul, page two • All Claims— nlease complete this section � Were there witnesses to the incident? Yes No Unkn (circle) If yes, please provide their natnes, addresses and telephone numbers: Were the police oi- law enforcement called? Yes N Unknown (circle) If yes, what departinent 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 landinark, etc. Please be as detailed as possible. If helpful, attach a diagram. 1� b � LD L 1� �� s�F{i �Lp S -/� W.f-i�cTVI.% if��11 1 G I� W�s Z7/�� Please indicate the amount you are seeking in com ensation fi�oin this claim or what you would like the City to do to resolve this claim to your satisfaction. 7Z � � [ � Z�13-. Vehicle Claims— nlease complete this section ❑ check box if this section does not applv Your Vehicle: Year Zoa � Make UD LVb Model SIoD License Plate Number q�q 6��V State��Color S J ��/�- Registered Owner � . � Driver of Vehicle � p � Area Damaged ST"k� �p� ��rfp��%�V��-.�(��'�%� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniurv Claims — please complete this section '�check box if this section does not applv How were you injured? What part(s) of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treahnent (circle) When did you receive treatment? (provide date(s)} Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pages B�'sionin�;thrs forn►,yon are starirrg that a!l infornralion you have p��ovided is true and correct 101he besi of yOG(Y IC/10N�ledge. Unsigired forms tii�ill not be p�•ocesserL Submitfing u fulse c(aim ca�►result in proseccrtinn. , I Print the 1�'ame of the Person who Completed this F r • N � I � 0 �J � Signature of Person Making the Claim: Date form was completed �Z Rcvised April 2007 . . .4�5:�,:r ' � , Glasgow Automotive INVOICE: 22181 12/26/2013 ";� Obee, Natalie � 7-10 University Ave. g24 Hague St. Paul MN JJ 10-� ST. PAUL MN 55104 (651) 227-8182 12192013 �612)716-1514 C http://www.glasgowauto.com michael@glasgowauto.com 2007 Volvo S60 License: 959GZY Odometer: 67100 Vin: YV1 RS592872636452 65254T2 AW55-50151 SN DSTC SILVER . . • . . . - • : • - . Labor performed on this job: Inspected steering and suspension. Found right $0.00 rear axle stay bent from the tow truck driver chaining car down! _ Parts: $0.00 .,t,, �.a..�::"L J2'.::�G Labor: $0.00 Job Subtotal: $0.00 Labor performed on this job: �arts required on this job: Replace right rear axle stay(bent). $137.50 9200217 STAY ROD 1 $55.74 $55.74 Alignment 4 wheel. $99.95 Parts: $55.74 Labor: $237.45 Job Suls#�tal: - - ��93..4 • - Labor performed on this job: Needs Tires!Also recommend to remove the $0.00 wheel locks. Norm's Tire Sales 276 i'�Long Lake Rd Roseviile, MN 55113 Phone: (651)483-4591 Fax: (651)483-8418 Nokian WRG3 Parts: $0.00 Labor: $0.00 Job Subtotal: $0.00 Invoice Summary I,the registered owner, hereby authorize the above repair work to be done along with the necessary material Parts: $55.74 and hereby grant you and/or your employees permission to operate the vehicle herein described on street, Labor: $237.45 highways or elsewhere tor the purpose of testing and/or inspection. I agree to pay reasonable storage on vehicles left more than 48 hours after notification of completion of repairs. An express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs,stor�ge, and any legal fees thereto. I Subtotal: $293.19 agree to pay costs of any attorney of collection fees. Payment is due at com�letion of work. Any returned check is subject to a 35.00 charge.All repairs have a 1year parts and labor warranty on new parts and 90 day paRs and labor warranty on used paRs. Tax: $4.25 � Total: $297.44 Page 1 of 1 Invoice:22181 Obee, Natalie 4337 '`� � :. �;, Glasgow Automotive INVOICE: 22181 12/26/2013 - Obee. Natalie 7-�0 Universiry Ave. 924 Hague St. Paul MN J J 10-� ST. PAUL MN 55104 (651) 227-8182 �2�92��3 (612)716-1514 C http:!/www.glasgowauto.com michael@glasgowauto.com 2007 Voivo S60 License: 959GZY Odometer: 67100 Vin: YV1 RS592872636452 65254T2 AW55-50/51 SN DSTC SILVER . . . . . . - • : • - . Labor performed on this job: Inspected steering and suspension. Found right $0.00 rear axle stay bent from the tow truck driver chaining car down! STD Labor Charge : $27.50 Parts: $o.00 Your Discount: $27.50 �abor. $o.00 Job Subtotal: $0.00 Labor performed on this job: Parts required on this job: Replace right rear axle stay(bent). $137.50 9200217 STAY ROD 1 $55.74 $55.74 Alignment 4 wheel. $99.95 Part .74 Labor: $237.45 Job Sutstata!: $�93.19 • S $0.00 ' j 7��tJI ERSITroYTpUE � Sr�fi51UL227�81$2�4 iERMINRI IO.; 8314 Parts: $0.00 UISA �abor: $0.00 ::>��4�i�l.so-c�i9 EXP;��:/�� SWIPED JobSubtotal: $0.00 5ALE_ 'r��f�'H� �u0555 It�IU: Da00�1 invoice Summary Dec 26a 13 12:48 AUT H� 08274C above repair work to be done along with the necessary material Parts: $55.74 A�1H11Ki 98274C permission to operate the vehicle herein described on street, Labor: $237.45 ting and/or inspection. I agree to pay reasonable storage on ��r,y� �,�y��S.� tion of completion of repairs. An express mechanids lien is cure the amount of repairs,storage,and any legal fees thereto. I Subtotal: $293.19 �n fees. Payment is due at completion of work. Any returned iINiHLIE OBEE >have a 1year parts and labor warranty on new parts and 90 day Tax: $4.25 Total: $297.44 CUS1uh�R COP4 Page 1 of 1 Invoice:22181 Obee,Natalie 4337 0 0 0 N � �_J � . L _� . � e � � l�_ � � cn N �,.� °..`-� .. � O � � J � a � � o g � ° o ° j _�� 'o M °• o �n °� °• °� � �` C� > c� o .- o � Z � C c- � � N N U � c� � c� tfl t� bs �, � > � W N aj � ' ,� W � rn aj •-• � 'vi > N � � � (0 � O � � � N � L � �.. 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V � c E � � •� � o Q � � �-' H o � � O V 0 W � � F�— � O a °� � } a � � o a � �' _ �; � � ti a �, w °o Z Y � � 0 M } � �' N Q ° C� U • N � � � Q � � Z � w � � ai �° � rn U E �- O � o �, a� � � V '�o' O N +_� O -p � L >+ � O � 0 > a U o a