Stierna RECEI!/ED �
MAR 2� 2014
,
NOTICE OF CLAIM TORM to the City of Saint Paul, Mi�qs�t�LERK
Minnesota S�nte Stntute 466.05 smtes�l�nt "...every persrn�...wlin claims dmnnges.`rom any rnu�Ticipnliry...sliall cnuse tn 1�e pre.rented to d�e
governing bucly of t/�e nninicipnlily wilhr�� 180 dnys after the n/leged/oss or injur_y is discovered a nofice stnfing the time,p/nce,nnd
ciretunstances thereof,nnd die mnount of compe�isation or other relie�'demnnded."
1'lease complete this Corm in its entirety by clearly 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 wilP receive a
written acknowledgement once your f'orm is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ����'�'�� Middle Initial � Last Name s�"ie rYt�
Company or Business Name __-. . -
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address ��°2S C� '�� a ��e, 5 ,
City ���'�'���t��o t� State �h Zip Code
SS Ya0
Daytime Phone ( ) - Cell Phone (�/a)7o.3- SS`7 Evening Telephone( ) -
Date of Accident/Injury or Date Discovered 3' ��—�/ Time 6• �S �/pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or l�ow you
feel the City of S int Paul or its employee are involved and/or responsible for your amages. � w�!S �Y'�y��_
�f ���t„� �h C(e ve .. c�� .n ��� • o r� a�h� e
,' ot l ; . ro�1� e _ l , uhn v� -�
l/ oa e � '/IF � � T s
S o c1 � C'_ a1 � �o ,Jti' c,H /� I E.'e E' C.' �
` �
`y, 2w ,C�re� ���� a . L c. a
o e� a.�d . �
Please check the box(es) that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was dam�ged during a tow
�.My vehicle was damaged by a pothole or condition 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 far 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 buth pages will result in delay in the handling of your claim.
All Claims—please comnlete this section
Were there witne�;ses to the incident? Yes � Unknown (circle)
Provide their names, 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 p rk or facility,
closest I dmark, tc. Please be as detailed as possible. If necessarx, attach a ciiagram. C Ie�E Iah� �9 UP_
ho r-���o��h� �eat� 8erke ly �4ve. S h��e ,a►�ures� ,���u n�ed� s�e �P,,.,
�u f�� �c re ati �e: � �s�e ,
Please indicate e am nt you ar se ng in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�l-37. aa
- --
-�eiiicleZTa�ms=Te'ase com Tte�his sec�ion - - � - " --�"- "- i3—check t�ozii�this secticin c9�es not-�t -
Your Vehicle: Year o�`� Make P�Hf�Gt.0 Model ra Y'��"" GT°
License Plate Number y�� ��D State�Color BI��c�C
Registered Owner T�i�H,�ti s +�1^
Driver of Vehicle �Lza,y,�s ��J�rha
Area Damaged ,�vl��el ati� -f��rP,
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
In jurv Claims—�lease complete this section �check box if this section does not��plv
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�niss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
�i1S?]e�_vOLLI ETTl�ln�i�r:
—--
- -..___
Address
Telephone
❑ Check here if you are attaching moi•e pages to this claim form. Number of additional pages
By signing this form,yoae are stating tltat ull information yoa� laave provided is true and correct to tlze best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date f'orm was completed
Print the Name of the Person who Completed this For . �"/��id S �• S l ��}r1�G(
Signature of Person Makin the Claim: _ �.�'��
g
Revised Februtuy 201 I
INVOICE Invoice No. 201414
---- - - _
METRO AUTO SALVAGE, INC. Search our inventory 24;7 at ��"�'�����
11710 East 263rd Street �Wmetroautosalvageinc.com ��T� ���A�iE
Lakeville, MN 55044 Specializing in Late Model Used Parts Since 1973
WC.
952-461-2186 Order# 168242/3 Tax Exempt#
800-252-5831 Claim Nurttber Date 11 Mar 2014
Customer PO# Time 14:22:08 CDT
Customer RO# Salesperson Chris
ConNdi�ct - "` ' l Sales Type Cash
Invoice To Ship To
VALUED CUSTOMER VALUED CUSTOMER
� 55044 55044
_- _ —_ —De iTve�ry�oun�e�SaTe _ --_ _ __ � ,._ �
I
Acct.Code
Stock# Part Description Price
00009546 2007 GRAND PRIX Wheel 100.00 I
17x6-1/2,5 spoke,double,silver(opt N85)6589 ,
V I N:2G2 W R554371162328
Part Comments: B.COND W/Gf;P,SMALL CLEAR PEEL BY CAP
Location: 1 YDW 10
. TI_Pn.,ERIF . . . . 1 . �i'! f-:. .. . . . � .
Email me, chns.metro@inteu�a.�er.,or call my direct fine at y52-461-8283
' Sub TotaL• 100.00
Payment/Credits History Tax1: 6.HE
03/11/14 Payment:Credit Card 106.88 Tax2: 0.00
Total: 106.88 Total: 106.88
Amount Due: 0.00
invoice Terms
-------- Thank Y�u Fo�vn,�r R��cinPCai Think pf MetrcAutq Salvage For All Your Automotive Part Needs!!!
- - - --
"*Sse back side for Company Policies."'
W a�roti�oTn� � /,��� �
� m" ' RECYCLERS ��R
W • .4SSOC(.aTlO'V �. ?'� i
S ���'
/ ����v How did we do? Please, complete the survey at
www.ntbcares.com Use password75599114 00005
TIpES•SERVICE� BRAKES• BATTERIES '
MN NATL TIRE & BAT # 894 * FINAL BILL -INVOICE** Page 1
9200 LYNDALE AVE S 'Invoice# 75599114 - RI
BLOOMINGTON MN 55420-3511 �rder Num 49977518 - WI
(952) 884-5330 Date/Time In. . . . . . . . 03/11/14 17 : 09 : 33
7ate/Time Promised. . 03/12/14 16 : 38 : 39
2007 PONTIAC GRI�ND PRIX
. Tag: TXT272 St : MN Mileage : 123871
Engine : VIN# 2G2WR554271175619
-------------------------------------- -----------------------------------------
Customer: 30177163 PO# : Ship To:
STIERNA,TOM
9725 CHICAGO AVE S
BLOOMINGTON M�7 5 5 4�0 ��
Opening Salesperson 12987250 Home# 612-703-5571 Work#
Email :
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Item Number Item Description Qty Price Each Extended
-------------------------------------�------------------------------------------
MC03322557H Mich Primacy NL'�;.V4 1 189 . 99 189 . 99
DOT # :N48K EWZX 2013 1
06852 22�,�5�R1? 97H, t;58��
�c , �o��
' Tire Disposal Charge Tire Disposal ��}iarge 3 . 00 3 . 00
PTT NC INSTALL TP 1 �
NCb WHEEL BALANCE _•.J CHARGE 1 ' -
KMTSL MOUNT AND INST:yLL 1 '
12985'v52 BRODSKY, RYAN J.
LTRF LIFETIME TIRE �:�TATE SVC 1
TPMSX Keep Existing TPMS Service Ki 1
RHWCadj MC03322557H � 1- 189 . 99 189 . 99-
DOT # :N48K EWZX 1513 1 i
SCRoadHazard ROAD HAZARD WA';�R.ANTY 1 28 . 49 28 . 49
---�� - - – -- — -��� ���i-�_—.� - �.g- - __
tC1CC TIRE DISPOSAL �REDIT 1- 3 . 00 3 . 00-
REC120K RECOMMEND 120, u00 MILE SVC 1
VISA Visa 30 . 34-
CARD NUMBER 938�5 APPR 156703
IF YOU HAVE A QUESTION OR CONCERN PL�ASE SPEAK
TO OUR STORE MANAGER, ROBERT L. TAYLOF.'
AT (952) 884-5330 �
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Special Credit :