Baldoni NOTICE OF CLAIM FORM to the City of Saint Paul, Min�esota
Mi�uaesota State Statute 466.05 states that"...every persoi:...tivho clairns dmnages fro�n any mw�icipalety...shall cause to be presented to the
governing b�xly��f the munieipaliry within 180 da}:c afler the�tllege�l loss nr injury i.r discovered a notice.ctating the time,plu�e,unJ
ciscumsta�ec�s the�eof,and the mnount of compensatiou or other relief demmzded."
Please complete this form in its enttrety by clearly typing or printing your answer to each question. If more space is
needed,attach addftional sheets. Ptease note that you will not be contacted by telephone to daNty answers,so provide as
much information u necessary to e�ain your cl�im�,and the amount of compensation being reqneSted. You will receive a
written acknowledgement once your form is received. The process c�n take np to ten vreeks or longer depending on t6e
nature of your claim. This form must be signed,and both pages completed. If something dces 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 �� ������ Middie Tnitial�Last Name �� l�'���� RECEIVED
Company or Business Name FER 18 2t���
Are You an Insurance Company? Yes/� If Yes,Claim Number? �^�'Y'�/ t'� E�.�'�►
SueetAddress ��� � ��`�°�l �
�� �1/� � Zip Code °`
City � State ,
Daytime Phone(����� '� Cell Phone( ) - Evening Telephone( ) -
Date of Accidend lnjury or Date Discovered ���'�� Time �''� am/ m�
Please state,in detail,what occuned(happened),and why you are submitting a ctaim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. ����
�-�n '(� � �i,.� �...�
, �
j;,,,,' � '�,a, ,
Please check the box(es)that most closely represent the reason for completing this form:
�My vehicle was damaged in au aceident ❑My vehicle was damaged during a tow
❑My vehicle was damaged by a pothole or condidon of the street ❑ My vehicle was dauiaged by a plow
❑My vehicle was wrongfully towed and/or ticketed ❑I was injured on City proper[y
❑ Other type of property damage—please specify
❑Other type of injury—please specify
In order to process your claium ou need t include co ies of all a licable documents.
For the claims types listed below,please be sure to inclu�e the documents indicated or it will delay the handling of
your claim. Docwnents WII..L NOT be recurned 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 aetual bills and/or receipts for the repairs
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
and/or receipts for the repairs;de[ailed list of damaged items
O Injury clauns:medical bills,receipts
O Photographs are always weicome to document and support your claim but will not be retumed.
Page 1 of 2—Please complete and return both pages of Claim Form
� �
Failnre to complete and retutn both pages will result in dday in the handling af your claim.
All Claims—olease comtilete this section
Were there wimesses to the incident? Yes o Unknown (circle)
Provide their riames,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,name of park or faciliry,
closest landmark,etc. Pl ase be as de � d as possible. If necessary,attach a diagram. �
L fv `h, ` ��
i
Please indicate the amount you are seeking in compensation or what you would tikc the City to do to resolve s claim
to your satisfacCion. � �f I t�l V� .,-P'.�„ �,p��z_�_��� �,�j,p�1i�i,L�� �� �
_ �
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year �1�2)��Make �c��'1 Model�
License Plate Number� State��Color S i�V`e�
Registered Owner �i�vl i�l i Gl ��i�' ��
Driver of Vehicle °� �'
Area Damaged Y�tv� .v�v..�S�� W��✓
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Qaims—please complete this section �heck box if this section dces not a�lv
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�eatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
I?id 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 yon are attaching more pages to this claim form. Nutnber af additional pages�.
r '
By signing this form,you are stating that all informalion you have providcd is tnte and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can resull in prosecution. Date form was completed ���! � �
Print the Name of the Person who Completed t�is F 1.� /� I l 1� Cl��ilM�
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Signature of Person Making the C►aim:
Revised February 2011
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_ Page 1 of 1
_ " ' CLAIR'S AUTOMOTIVE Invoice
1341 ST. CLAIRAVE 151485
St Paul, MN 55105-0000 Estimate Ref#18,697
Shop Phone: (651)698-5632 Date Printed: 02/06/2014
Printed Time: 11:47 am
HaURef:5 Time Promised:
Baldoni, EMILIA 2006 SCION XA L4 1.5L 1497CC FI GAS N 1 NZFE
908 carroll VIN: JTKKT604160138007
Saint Paul, MN 55104 �icense:3olKZG Mileage In:48,539 Datewritten: ovos�zo�a
Home: (612) 296-6024 unic#: Mileage Out:48,539 Written By: DALE
Cell: �onn:sios Save Old Parts: No
Job Name Description Technician Qty List Extended
Job#1 /oil change/rear
wiper/wi...
Part OIL CASTROL GTX 4.00 4.75 19.00
Part FIL OIL FILTER 1.00 10.00 10.00
Part front blades 2.00 14.50 29.00
_-!
Job Total: 58.00
Job#2 ,
Part rear wiper arm /caps 1.00 52.99 52.99
Part Wiper Blade 1.00 12.00 12.00
Labor 1 Work Requested-rr rear arm 0.20 97.25 19.45
Job Total: 84.44
Parts: $122.99
Payment Date Type Method Amount Labor: $19.45
Sublet: $0.00
Misc: $0.00
Payment Totals:
Hazmat: $2.25
Supplies: $1.07
Tax Total: $9.38
Invoice Total: $155.14