Reed . RECEIVEC�
� MAR 19 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne��TY CLERK
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to 6e presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form 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 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 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 �J�1l.U�t1 Middle Initial�Last Name���
Company or Business Name '—'
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address 32-� �✓'�.en b r�e� s�
City ��Q�nG-(.S ��S State m/� Zip Code ����Z-�
Daytime Phone(�)�-��Cell Phone(�)�-31� Evening Telephone(�,�- ���
Date of Accidend Injury or Date Discovered 3��� '���`� Time�am�
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 employees are involved and/or responsible for yo r damage .
vi n 0 CY� , fiC Y ;
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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 damaged during a tow
�My vehicle was damaged by a pothole or condition di the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed andlor 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 vou 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.
�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—please comulete this section
Were there witnesses to the incident? Yes No Unknow (circle)
Provide their names, addresses and telephone numbers: (�1�--'
Were the police or law enforcement called? Yes N� 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 facility,
closest landm k,etc. Please be detailed s possible, If ecessary, attach a diagram. RanG�Q I.�YI �e f/1
�-�-- �C��Q��►�f U���� o� ��- CGt�1t►-� n-eS
Please indicate the amount you are seeking in compensation or what ou would like the City to do to resolve this claim
to your satisfaction:� �"� P �I' Y1 / �1�7�`?f-
G
Vehicle Claims—please complete this section ❑ check box if this section does not annlv
Your Vehicle: Year 2,0. Make i�l�NlLIG( Model C) V �C�
License Plate Numbe State m�a Color blUe_
Registered Owner
Driver of Vehicle u W V�
Area Damaged G1 Y 1 V Q r �i1�- �l Y�,� D0�i�e
City Vehicle: Year 1�1F�' Make �_ Model ,/l/A'
License Plate Number Al� State�i`�' Color N'fr
Driver of Vehicle(City Employee's Name) �ll A'
Area Damaged N W
Injurv Claims—please complete this section 4iQ check box if this section does not aunlv
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
1�Check here if you are attaching more pages to this claim form. Number of additional pages��
By signing this for�n,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �I i� � �y
Print the Name of the Person who Completed 's Form: �Q11� 11 � �eeC/
Signature of Person Making the Claim: � � � �`
Revised February 2011
.Gmail - RE: Pothole Page 1 of 1
�
' �,�
Dawn Reed < mnreed3270@gmail.com>
� �;�,;�„��,
__. _._ _ _..... _._
RE: Pothole
1 message
*CI-StPaul_Potholes < Potholes@ci.stpaul.mn.us> Wed, Mar 12, 2014 at 5:33 PM
To: Dawn Reed <mnreed3270@gmail.com>
Work order written up to repair the potholes.
From: Dawn Reed [mnreed3270@gmail.com]
Sent: Wednesday, March 12, 2014 2:13 PM
To: *CI-StPaul Potholes
Subject: Pothole
Last night at approximately 7:40p.m. I hit a pothole on Randolph Avenue in St Paul (in front of St
Catherine's University)that damaged my car. Please look into fixing this pothole and letting me
know if there is any claim assistance available for this damage.
Thank you
Dawn Reed
https://mail.google.com/mail/u/0/?ui=2&ik=b5ee8b9afe&view=pt&search=inbox&th=144... 3/17/2014
� * INVOICE * #530661
TIRES PI,IIS TIME IN/APT:
�.
4612 CENTERVILLE ROAD DUE TIME:
WH I TE BEAR �, 1�II�T 5 5110
PH. 651-653-8711 WAITING / DROP OFF
whitebear@knapquist.com
www.tiresplusminn.com
-Sold To: ACCOUNT#: 503398
DAWN REED
DATE : 03/12/14
Ph: (651)398�3178 INVOICE #: 530661
Billed By: SALES
2008 HONDA CIVIC Salesman : SCOTT F�NNEDY S#:3 Rt:
�1341 Mileage: 78945.0 Tx:Y EX#: Ct:R COD: IWS:
VIN#: 1HGFA15538L042580 KID#: Parking Space#:
Onit Extended
Qnantity Product # Size/Description/Mfr# TC MC DP BIN# Price F.E.T. Amount
�t�,ttttttt,tttttt�ttt�,t��tt,tfttttt,tttt+,t,t,t,► Z
, DRIVERS FRONT TO BE REPAIRED Z
. SPARE CURRENTLY ON VEHICLE Z
,►,tt�t�,ttt�t,t�t�t,t,t�tttttttt�,tttt����tttt,►f Z
1.0 OPT UNIROYAL TP TOURING P205/55R1691H 1 R 102.00 102.00
TPP PARTS T�itE PROTEGTIQ�i PLRN � K 6 , 13.00
1.0 VSTM+ PARTS VI�VB STEM ` 1 K D NO CHARGE!
1.0 TRF FEE TIRE RECYCL��'EE } R �
SBOPSOPPbY SBQA SOPPLT TiRE.F�E 1 �4 E
400-2� ��SMO�FiT��M001iT fi� `.�C w `°,= NO CHARGE!
. Aismaunt ti.�� from,xheel. Cl�► and .' _� :Z
. inspect bead�of x�ee1.A�ns�a11 neK R°. Z
. valve stem. Inflat�a to p�npsr PSI:` ' K Z
, Explain Manufacturer's Warranty. � �
400-1+18 LIFETI2� BALANCE � W
. : Remove rheel, computer spin balance. R 2
. Torque lug nuts to manufacturer's specs. R Z
, tf Free Lifetime Flat Repairs, Rotations, R Z
. Alignment Check b Vehicle Inspection. R Z
, +f All Lifetime services above are b�sed R Z
. on 2/32nds tread depth of the tire. ' R Z
, �+ Tires Plus requires retourquing of lug R Z
. nuts on alloy Kheels within 50-100 miles R Z
. after the removal of the wheel from the R Z '
. vehicle. R Z
+txt��t�t�tr,t��ttt�tt��t,ttttt��ttt��tt���f g Z
, POT 80LE CAOSED SIDEWALL OF TIRE TO BLOW R Z
. OUT AND DENT RIM � Z
, TIRE WAS AT 5/32NDS OF TREAD NEW TIRE IS R Z
, 10/32NDS. WARRANTY CREAIT IS $38.25. K 2
ORIGINAL INVOICB# 96770 IN OLD SYSTffi4 R Z
� « Page 1 of 3 »
Received By:
, * INVOICE * #530661
TIRES PI�IIS TIME IN/APT:
4 612 CENT�RVII�`LE ROAD DIIE TIME:
WHITE BEAR LAKE, I�T 55110
PH. 651-653-8711 WAITING / DROP OFF
whitebear@knapquist.com
www. tiresplusminn.com
-Sold To: ACCOUNT#: 503398
DAWN REED
DATE : 03/12/14
Ph: (651)398-3178 INVOICE #: 530661
Billed By: SALE5
2008 HONDA CIVIC Salesman : SCOTT E�NNEDY S#:3 Rt:
XXIQ341 Mileage: 78945.0 Tx:Y EX#: Ct:R COD: IWS:
VIN#: 1HGFA15538L042580 KID#: Parking Space#:
Unit Exteaded
Quantity Product #. Size/Description/Mfr# TC MC DP BIN� Price F.E.T. Amount
, ��ttt,rttttt�ttttttt+��t��,rttt�tttt�t�+t:f�t R Z
-1.0 ADJTIRE(TPP) ADJ TIRE TIRE PLOS PROTEC TION 1 R M 38.25 -38.25
, �,tt,t,rrtt�,t�ttt�,►,rt�t�t�t,ttftttttt,rtt�t�t�+ g Z
. HIT POT 80LE CAOSING TIRE TO GO FLAT' R Z
. INSPECT AND ADVISE R Z
, � g ;Z
. C1�,L I$ t�EDED R Z ,
. FRONT WHEEL $49.99 ' R Z
. FOUtt T�TB�EL $69.49 ; K . Z
, t�r+�rt�t.��tlt�t��t�t�r�Ettttt�t,t#irttr�t�f�it��t '�� Z
AL02 ALIGNl�NT FOOR 1�EEL i R Z
400-4WA ALIG1i�ENT 4-WHEEb } K 5 99.99
��trtttt�tt,ttt�+ttt�f,r�tttt��tttt,�ttftrt,rt. R Z
. Road test nehicle. Check all suspensioa R Z
. and steering parts for xear. Check tire R Z
. pressure and condition. Check riding K Z
. height. Check alignment on all four R Z
. rheels. Adjust caster, camber, toe-in, R Z
. and thrust angle as needed on all R Z
. four rheels. Center steering pheel. R Z
,rt�ft�t,rtt,►ttftxt�tt����r,rt�tttttt�fft:t++ R Z
DISALIGN DISC DISCOUNT- ALIGNMENT R 5 -30.00
SS99-5 S80P SOPPLIES/SERVICE E 6.30
Received By: « Page 2 of 3 »
, * INVOICE * #530661
TIRES PI�US TIME IN/APT:
4612 CENTFrRVIL�E ROAD DUE TIME:
WH I TE BEAR LAKE, NIl�T 5 5110
PH. 651-653-8711 WAITING / DROP OFF
whitebear@knapquist.com
www.tiresplusminn.com
-Sold To: ACCOUNT#: 503398
DAWN REED
DATE : 03/12/14
Ph: (651)398-3178 INVOICE #: 530661
Billed By: SALE5
2008 HONDA CIVIC Salesman : SCOTT I�NNEDY S#:3 Rt:
7�Qd341 Mileage: 78945.0 Tx:Y EX#: Ct:R COD: IWS:
VIN#: 1HGFA15538L042580 KID#: Parking Space#:
Unit Extended
Quantity Product # Size/Descriptioa/Mfr� TC MC DP BIN# Price F.E.T. Amount
�
�
i
��
I
Merchandise Services 6 Other F.E.T. Subtotal Sales Tax Total
63.75 89.29 0.00 153.04 4.54 157.58
Comments: Terms: PO# DOE DATE AMT. DUE t�isc. Adj. . . . . . . . $ 0.00
Cash or Check #: $ 0.00
Credit Card. . : MC . . $ 157.56
Balance. . . . . C . . . $ 0.00
Received By: « Page 3 of 3 »
Started: Ol/04/14 3:00 PM Promised: Completed: 03/12/14 5:40 PM
� This value is not within specificatian. 7ire wear, handling and safety
pro�lees eay result.
Na�e
Address
Telephone
Vehicle (VIN)
License
Technician
�ileage
Tiee Printed 311�/14 �:57 aM
Honda : Civic : �00E-11 : with lb", 17" Wheel (LX/EX/8i Models) : with "C" Staaped Rear
Upper Control Ar■
Front : Left Front : Right
----------------------------------- -----------------------------------
I Actual I Before 15pecified Rangel I Actual I Before ISpecified Rangel
I--------+--------+---------------I � I--------+--------+---------------1
i DJ.8q1* i 1.l�m* i -0.5�' f�.5°1 i Ca�ber I -1.00* I -1.2°'* I -0.5�' �.5°' I
I . i . I 6.�°1 8.�� I Cast er I . I . 1 b.�°' 8.f�m I
I �.02'° I-i.720* I -�.08�' �.�8°J I Tae i f6.�0m 1 1.65�'* I -Q�.�8°' 0.08m I
I . . . . . i . . . . . I . . . . . . . . . . I 5AI I . . . . . I . . . . . 1 . . . . . . . . . . i
i . . . . . i . . . . . I . . . . . . . . . . I Included Angle f . . . . . 1 . . . . . i . . . . . . . ... I
I ;. . . . . I . . . . . I . .. . . . . . .. I Turning Angle Diff. I . . . . . I . . . . . I . . . . . . . . .. 1
� -7--------------------------------- F�ont -----------------------------------
„ -----------------------------------
I Actual I Before ISpecified Rangel
;.- i--------+--------+---------------I
Ct^055 Ca�ber I 1.8°1* I 2.2°* I -0.6'� 0.6m i
CY`OS5 Gaster � . � . � . • �
Tota�1 Toe I fd.02°' I-f�.070 I -�. 16Q1 fA. 16°1 I
----------------+------------------
Re,�r : Left Rear : Right
-----------------------------------
-----------------------------------
I Actual I Before 15pecified Rangel - 1 Actual I Before ISpecified Rangei
I--------+-----j--+---------------I I--------+--------+---------------I
1 -l�.5°1 I -�3.4°1 I � -1.5°' f�.3°' i Ca�ber i -1.4'" 1 -1.4°/ I -1.5m 0.3°' 1
I �3.07�' I !3.0101* I 0.04A1 �3. 16m i Toe I 0. 14°' i �.020* I �.H40 H. 16� 1
-----------------------------------
-----------------------------------
Rear
-----------------------------------
I Actual 1 Before ISpecified Rangel
! i--------+--------+---------------i
�Total Toe f 0.21°' I �.03� I 0.08° 0.31Q1 I
Thrust Ang 1 e I-Q�.�4°' I-0.01°1�_1 . . . . . .. . . . I
---------------- ----------------
,
TIRES�PLUS WHIfE BEAR LA ��
4fi12 CENTERVILLE Rp
WHTfE BEAR L MN 55127
DATE:03/12/14 TIME:17:39
MERCHAIdTID: JA27664351001
CREDTf CARD ,'
MASTERCARD SALE
CARD� ************2145
EXPIRATION DATE **I**
SEQ: 512021
' APPRQVAL CQDE: 53413Z
. ENTRY METHOD: SUVIPED
� PRODUCT QTY PRICE AMOUNT
GEN AUTO MERCH 157.58
'" TOTAL AMOUNT; $157,5$
APPROVED 53413Z
TI�ANKS FOR YOUR BUSINESS
. �,� CUSTOMER COPY