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Robinson RECEIVED � MAR 13 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, M�'c�o�ERK Minnesota State Stntute 466.05 stntes thnt "...every persnn...who claims damages from any municipality...shall cause to be presented to the governrng 6ody of Ihe municipality within 180 dnys nfter the nl/eged loss or injury is discovered a notice stating the time,place,�nd circumstances thereof,and the nmount of compensation or other relief demanded." Please complete this form in its entirety by�learly 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 depending on the nature of your claim. This form must be sigi�ed,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��` Middie Initial Last Name ��b���� Company or Business Name Are You an Insurance Company? Yes No Tf Yes, Claim Number? Street Address �� � City �(l�l n� �(11�.1 State �'�v Zip Code ��� Daytime Phone( ) - Cell Phone(��l��-��vening Telephone( ) - Date of Accident/Injury or Date Discovered ���� ��, �� �-t Time ��� �Z am pm Please state, in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employe s are involved andlor responsible for your damages. d `�i �0 S � 1�1 2�h a o � � w �� -e. ,�1, ' -� c�c� -� �-- od I�U�I � �� � i'r�i � �(-D 2 1��F1'Y� r CpS`� ti.l.� G� Yl0"� ���71� � o � 1Q4�P �'�'lg , Please check the box(es)that most closely represent the r son for completi g this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow �My vehicle was damaged by a pothole or condi[ion of the street ❑ My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify � In order to process your claim You need to include copies of all applicable documents. 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 $500.00;or the actual 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;detailed list of damaged 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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease complete this section Were there witnesses to the incident? Yes � Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement c led? Ye No Unknown (circle) If yes,what de art en[or agency?� C�s�^e#-o}'�report# ����8' g�� n'l-C 'l� `NVI� Gl� o��r s - Where did the accident or in�ury take place? Provide street address,cross stree[, inter tion,name of park or facility, closest andmark,etc. Please b as detailed as possible. If necessary at ach a di ram. c 1 � �.0� l3 I�t Rr�_�j''.�P� r-t� � � ���-a�i�n�rY� I�P��.t� l�lJ�4 Please indicate the amount you re seeking in com ensation r what you would like the City t do t resolve this claim to your satisfaction. ��J� . 'r�� � �=2 C2 �'S � Vehicle Claims— lease com lete this section � ❑ check box if this section does not a I Your Vehicle: Year Make Model License Plate Number State C r Registered Owner ` Driver of Vehicle � � 0 Area Damaged 7 " 0'1Y-e �� . City Vehicle: Year ake Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injury Claims—nlease comnlete 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 Treatment(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�. By signing this fonn,you are stating that all informatio�:you Izave provided is true ai:d correct to the best of your knowledge. Unsigned forms will�zot be processed. Submitting a false claim can result i�z prosecution. Date form was completed 1/�� I 2� 2t1 I� Print the Name of the Person who Completed tl�is Form: l '�S ���I�.S �� Signature of Person Making the Claim: Revised February 2011 _. �_. �.. � % .� �>>�- ,f��� � � - � � . , � �, ��, �., `'��� � �. � � -,._. >, ,� � � 1'`" �-S� �. � �. ��� ¢ ��° � , - A. �. �� � � < __ �< . �.r � t-��: � � ��� � � � ��� y � ��.. � � � � �����'��� � � ������ ^�r �''� p � / �zk.� �� . . �..� ,.. � .. � � fa � f t� s .. . .� � � � � 5`�'3'�:,� "��� z3"�'�� �,.`�'�..�x��e _ � � mt� n�y`��� y. " ,,�� � r iY . � � b d '� A', .� ^�° '8"%E x' +` �, .�'; � � � ��: �' �'.. . , • i "s' , � � 'N'' �. � >,""� ^9'„ '��� - _ . � d. 1����i��� V '�}i � �� �"�� � � -:��a � � � s ���k�'� �i1� ��i���1��iu I' a�Y, �'�.� rs� y _ � i�, r .r � ;� � 4, M�ii�id�rt�I�1Nx�i V ���,- i,� ,�� ��q ,y �y '� '�- -� � x II �1 Iy�I iy,lY 3�`�; � �`�, � ,f' w.�� £� � � �^ ���3���, f�p I '� 9u �'" ,�,R+ y�, f� '�-i�; ,��. y-'L' �.. 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TURNED DOLLY $ ggt,qq�S CHARGE To���p MILEAGE $ CHARGE urircs WINCH $ CHARGE Sub-Total $ Tax $ � DAYS STORAGE :�M�UNT . � � GALLONS F[JEL $ TIRfi $ - CHANGE SO C�i LOCKOUT $ ❑ CASH N� $ START ❑Ct�CK OTHER $ " TOTAL $ ��; Lv ❑�sA o M� ❑,,�,�x ❑OTI�R Customer acknowledges that AAq and The Auto Club Group shall�not be �pgDq(��'���„ /1 , responsible for the customer's vehicle aRer delivery to the location authorized AUTH#rJ�J y�� by the customer if the vehicle is rowed to a r,losed faciliry at the customer's (Lazt 4 digits only) . . request. . . . � PPSk E� �^�' � , . � � REC'D BY � 'V � �R f ,.y ` �" 2 TRUCK NO Z� - ------- White-Member Yellow-Club PiNc-Club - � _ � ,. , EXPIRATION � � DATE QTM CLASS : DESCRIPTION i PRICE AMOUNT CHECKED I J - �> y� DATE AUTHORIZATION � W� - TOTAL ; N C - REFERENCE NO. SERVE � , ' TAX SIGN HERE � ID-FOLIO/CHECKNO./LIC.NO.STATE REG.iDEPi C�ERK TIP V MISC. /\ The issuer ot fhe caid idendfied on ihis item is authonzed to ��� �� �' �� ' � �- j upon pmper presentatlon.I promise to pay such TOTAL(toge er�wifh ount shown as TOTAL . . .. . . ihereon)subject to and in accortlance with ihe a�ll oNer dta�ges dua � , agreamant goveming the use of wch prd, - �,��� ��� ,i�' MR. TIRE SERVICE Repair order#$041965 1201 RICE STREET Date : 3/11/14 ST PAUL, MN 55117 Page : 1 � 651-487-2851 Center: 1 Customer: ROBINSON, CRYSTAL Vehicle : 1998 BUIC REGAL Address : 105 MONTANA AVE W License : 503CDJ Unit : City: SAINT PAUL, MN 55117 VIN : Phone 1 : ( 612 ) 384-1247 Ext: Engine : Trans : Phone 2 : ( 651 ) - Ext: Mileage : Colr: Op Tech Description Labor Parts Subtotal Quan Part Number Part Description Reason for Replacement Price TI1001 JE MOUNT & BALANCE ONE TIRE 10.00 98.33 108.33 2.00 WW WHEEL WEZGHTS 1.00 SC1212 VALVE STEM 2'99 1.00 C12107 225/60R16 MC440 91.84 1.00 TIRE FEE 3.50 DRT500 JE REPLACE STUD ON PASSENGER FRONT 60.00 60.00 Discoun 0.00 -18.00 -18.00 a � � w --� � x OK Bad Recommendation Oh � � � � rt v, x A 2 a�i ?? t"'� � a x � _ . . . � -- x T � @ � � � o � �_ o rt � o x �' o . :� `° ° 6' m �n . —1. rt � �� m .-.�N ym Qa ♦/� 2 3 � V/ 0 �D O . � z m m � �€�i ��.�o . °c o m � � /p w �z�m� � � � vo � a J � -�c� m rocn°-'�m . ��m e-�'�- N �7 � . m �l-m-1 . . n a � � � �-+ � c.r� "' . m m t"" c�s+ �. ': r�- m a -°�°.• a � . . � c.c w � Q . o . m I hereby authorize the repair work to be done along with the necessary parts Labor: $70.00 and materials and hereby grant. you and/or your employees permission to operate Pa1tS : $76.83 the vehicle herein described on streets, highways or elsewhere, at your des- SUblet: $O.00 cretion, for the purpose of testing and/or inspection. An express mechaaica OtherFees : $3.50 lien is hereby acknowledged on the above vehicle to secure the amount of re- $UppIIQS $2.0� pairs thereto. I understand that dealer/owner is not responsible for delay or Subtotal : $152.33 other consequence due to the unavailability of parts shipments beyond their Sales Tax : $5.86 control. Not responsible for damage or articles left in car in case of fire, Paid sy: Total : $158.19 theft or any other cause beyond our control. MSTR CHARG VISA WARRANTY IS 90 DAYS OR 3000 MILES WFIICH EVER OCCURS FIRST, UNLESS SPECIFIED pay Ref: Paid : $158.19 OTHERWZSE! Due : 0.00 X � �