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Jehle N4TICE 4F CLAIM FORM to the City of Saint Paul, Minnesota :L/i�irresolu Sru1e Stattrle lb6_f1�slutcts tkal "...everv pe�:srin...irlro claitns dantaQes;fi•om mit'»ttuliciptrlily...slrall cturse�10 be presenled�n dre �m�enri�t,�horly�jtltc municir�tlffy trlNtin I811 da}s ttJter 1he tr!legecf loss a•i��ttry is rliscvvered a�rolice slr�li�;r,�i/re tinre,pluce,rrird circttnrstauces�/rereof nrirl tlre aum�ait oj'co�+ipe��scition r�r ot/rer relicf denani�rlerL" P�ease eompiete this form in its entiret}�by clearl�°typing or printing}�our ans�rer to eacl�question. If more space is needed,attach additional sheets. Please note that you may or ma}�not be contacted by telephoac to discuss your claim circumstances,so provide as mucl�information as necessar,y to explain your claim,and the amount of eompensation being reyucsted. This[orm must be signed,and bath pages compicted. If somcthing does not apply,ti4rite`n/A'. SEND COti�iPLETED FOR11I f1ND OTHER DOCGR�IENTS TO: CITI` CLERK, 15 WEST KELLOGG SLVD,310 CITY HALL, SAI�IT PAUL, NIn 551U2 First Name ���ISS� Middle Initial ►� Last Name J �c��e RECEIVED Company or Bu.siness Name, if applicable_�' ��Y4X� (M;Q,Qs� �RN �8 2���F Street Address _ ��U v.l ���.�.ti� � �, /�ve CiTY CLERK - -Ci ty_JC!��n tW�ya e�'f State ►'�� Zip Code �S�-{o S Daytime Telephone{ �I SZ) �3 � - ZS2�'� Evening Telephone(�f�2 � �3 g - 2�Z� Date of Accident/Injury or ate Di es overe �`��`� � �~ Time << a�'pm (circle) Piease state, in detail, «hat occurred, and why you are subrnitting a ciaim. Please indicate why or how you fccl the City af Saint Paul ar its cmployees are involved and/or responsible. �'ar c.,c+� -�a�,.co� o n ��is, �`n �.�-�f-�.ro'� U.c+'1 /'G" . ��� � Go�s - �'�.4_ kY�W r � .c� t � r J �a�-Q. ��C �I� � •�. rQ f n �.. f�- � •,� , a,,,a,' ab cA iL r�e�t-..r v . Please check the box{es) that most clasety represent the reason for completinb this form: ❑ Vehicle was damaged in an accident J�'Vehicle«�as damaged durin�a tow ❑ Vehicle was damaged by a pothole or condition of the street CJ Vehicle was damaged by a plow L7 Veliicle wa.S wrongfully towed and/or ticketed ❑ Injured on City property 0 t7ther type of property damage-please spccify � Qther type��#�}�ry—�lease�pecify ❑ Other type not listed—please specify In order to pr�cess your claim �ou need to include copies of all applicable documents. This is a general �uideline of what should be submitted with a claim form, but it is not a11 inclusive. Yau may be askcd to provide additional information depending on your claim. � Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle;or the actual bil]s andlor reccipts for the repairs O Tocving claims: legible capies of any tickets issued and copies of the impaund lot receipts � Other property damage:repair estimates, detailed list of damaged items 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 Farm Failure to providc a completed claim form�vill result in delays in processing. LUUL I!-`ai�r Pa:�ina� / /� z Pa�aidiuo� senr w�o� a.�en i :ut��J�aq��un��y� uos.�ad 3o a.�n��a�zs ��a� �o S f � :ur.�o,� s.q� Pa�a�dwo� oq� uosa�d aq;,�o atue� aq�;ur.rd �um��iaasold trr t/nsa.�ua�ut�v)a as�nf n�Yttrurrrrq�ts p�ssaaoari ay luu irn,Su�,,�J pau°�siir� -��pa�mou��n�,i jo ysaq ar1�ox��a�oa pun arr�sr pap�an�d annt�rto:t rtoatmu.rujur��n lny�8ut�n�.+a.rn»a.0�wl�f srtl�Suru�».f� •-Z sa�ed ��uoUtpps;o.�aqmn� •ui.�o;[uc�ia s�u�o;saosd aaou��atqae��g a1B noli,{�aaaq xaau� � auoqda�a,j, ssa.��py :�a�Coldut�.�no,C3o au�e� ((s)a�ep ap�,to.�� �xao�sstuz no�f pcp uaqM o� sa� �,�nfui sno:t�o lins�i e s� xiaan ssrui no,�prQ auo�daial, ssaiPpy :(s�zaprno.id ie�ipay��o aure� ��s}a��p apcnoid) _ i.luaux�a.�-�ni��no.0 prp u�c{,4,,J_- (ai�ai�) �u�uu�ai,�xaa� o���nuu�Cd oN sa� ��uaw��au Ip�ipauz au�nos no�a,�r.H �,pa.�nfur asa���Cpoq ano�C3o(s)ueci��q,M iPamCu� na�a.��m h�aH ni � �ou saap uot��as szk� }i xaq���r�a� uoE;aas siq}a�a� wva as�a� –surr��� ,�n,ui p��r.tu�a eai� ' {aureN s,aa�Cojdui��i���) o��rqa�3o.�anuQ soio� a;e�S •r�qu►n�;a����asuaai-� i�P°� ��L\I .�a1� :a���ual��t�c� .�,a..� -+`'' " , °�" _ p���u�Q�asd 'rl ai�n.�an�o aant.cQ �I �� - " 7 � 71 .�atrnnp pa.�a�sr�a� �'�r�T—lojo�(vv�a���S � saq�unNat�i�asua�rZ ` "z �aPoi,� -.w�� ������4oZ .c�a� :af�i�{an.�no� [ ��ou saop uot��as scu�3i xoq x���{� � uoi��as sry�a�a� uioa aseaj –suiECi� a�a[uaA -uot����st�BS mo�C o� �.utE�� s[t{i a�josai a� op o� �C�i� aq�axri pjnoht noA�eu:�n ia Lu�Ei� s��� uio.g uo���suaduio�ui �uixaas a.ce no�C l�mocue a�al���pui aseal� / �.^.� p' ' '^#� �J h zZ �� �� �� •tu�.r.�e�p E q���e `In�dtac{�I 'a�qcssod s� palie�ap se aq ase��� •��a °xl�uipue��sasol� ���iII��� Io x.�d�o a�ueu`uo►��assa�ut=�aa.��s ssaa� `ssaipp� �aai;s apino.�J �a�eid ax���nfui.�o�uapt��e a�{�ptp a.ca� #�o�a.t.�o��se� �,{�ua�E.�o�uaux�t�dap��q�41 `sa�i�I (�iaat�} unlau�ul� sa� LPaII���uauiaalo�ua n��j� a�i�od aq�aiaM D 'Y �/° � a r,.i�-�-t..-r�P�v �e J' �f!' f x�v ,t . ' �' S :ssaqumu auac�daia� pu� sassa.�pp� �saut�u.��a�a apino.id as�a�d`sa�C�}� (al�a►�) n�o n c�� sa� ��aapi;�ut aqa o}sassau�Tn���.���{�a.�aM uop�as stq�a;�� uio� asea� –swi�[� II� o��a�sd'�ned�ureS�o:��� `EU.�o� urie���o aar�a� General Milis Auto Service Center � � -:_ =�����.., ;>����''= Bill To Alyssa]ehle Plate 028 KYR Description 2006 Make Toyota Camry XLE Engine L4-2362 2.4 USA Odometer 181,515 Phone (763) 764-2523 VIN 4T16E30K86U661169 Mobile (952) 738-2525 Email Alyssa.)ehle@genmills.com PO # N/A Work Order# 0000084893 Invoice Date Jan 22 2014 Invoice # N/A Appointment Jan 22 2014 11:32 am Svc Advisor Grenson,]oe Promised Jan 22 2014 5:00 pm Technician Slabiak, Paul Services Requesred _Accessdri�s-Repafr/Service/ Replace ` Provide estimate for plastic skid plate hanging down on vehicle Labor $43.20 * Sub $43.20 Total Labor $43.20 Total Parts $0.00 Total Before Taxes&Miscellaneous Charges $43.20 (*) Shop Supplies $2.16 Totals $45.36 Authorization Comments Customer Signature: 1 General Mills Blvd. Golden Valley MN 55426 763-764-4276, asc.appointment@genmills.com, Work Order#0000084893 Page 1 of 1 ��� ( I � .. � , . m � � Z Z > � � ° N � 2 � � � � � o U o O O (fS � a � �- � .� � ° ° � ro � � � � c iri � � � � � ai � m J � `>' U � � c3 0 � y � ` � � U � � � V U � V � � '� 3 "'�" j . � � O p°- �u c � � � � � I ' .; � � � � � � Q � � � r � � � I � O � � 1 � z � � � ( � � � � � a* � m � y � ' X � � � i � � '�' C � � m° � � � Q � � j , � cn � � J I i � � � o �=1- C T -O .0 = ' � - � � f= � O � - - s -�-- � ( U � � � Q�+' � � � i ^ N .. � U � � Cil t� � '� CC' cY6 Z � � Z > S i � � � > > � i`� G� V a I