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Merrill � RECEIVED ; _ MAR 2 6 2014 NOTICE OF CLA�M FORM to the City of Saint Paul, Mi��s�t��-ERK Min��rsata Statt Stnttrte 4b6.05 states thal"...every persnn._.who clain�s damages frone nny municipalitv...shn!/cause to be presented to the governing l�ody of tlie municipality within 180 days after�i�e alleged loss or injurv is discovered a notice stating tfee ti►ne,pince,and circunrstances thereof,and the amount of compensation or otker relief dernanded." 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 w11 not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of cornpensation being requested. You will receive a written acknowledgement once your form is received- 'I'he process can take up to ten weeks or longer depending on the nature of your claim. Tt�is foc-m 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, 314 CITY HALL, SAINT PALTL, MN SS1.02 First Name � n`��` Middle Initial_�Last Name I"�� V- Y'� �� ! > Company or Business Nanne " Are Yoa an Tnsurance Company? Yes;f IVaj If Yes,Claim Number? �.�/ Street Address.� ° I � ��� ^" 1 Q-� �t City St" - i�u, State M� ' Zip Code � S i C S Daytime Phone �(LS� )E`i` - C IC Cell Phone(.�, - Evening Telephone( 6si )6`i9 - 0`�/(� Date of AccidenV Injury or Date Discovered -7 �ZG " I� Time �1°G 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 Sain�Paul or its employees are involved and/or responsikle for your damages. l i r d rl "'_X i"I'� ��� G i1 0` 'r. '� o Q ,� 't,l, cs. r •� o`` G G G` � o � � ( U ` �O �' � ` i, - �'1 G � d .v"C. Q i� C� t c� � 2� �- C..0 Cz , 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 vehiele was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow ❑My vehicte was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage—please specify 0 Other type of injury—please specify In order to process your claim�ou need �o include copies of all apnlicable documents. For the claims types listed below,please be sure to incIude the documents indicated or it will delay the handling of your claim. Documents WILL NOT be retumed and become the property of the City. You are encouraged to keep a copy for yourself before submitting your cIaim form. �Property damage claims to a vehicle:two estimates for the repairs to your vehic2e if the damage exceeds $500.00; or the ac uaI bills and/or r��P*^r nr�rh_e ren ' O Towing claims: legible copies of any ticket issued 1nd a copy of the impound lot receipt O �ther pmperty damage ctaims: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 bilIs,receipts O Photographs are alw�ys welcome to document and suppo�t your claim but will not be returned_ Page 1 of 2—Please complete and return both pages of Claim Form Failure to comptete arid return boW pages will result in delay in Ehe handling of youc claim. All Claims-please complete this section Were there witnesses to the incident? Yes�/ No Unknown (circle) Provide their names, addresses and telephone'r�'mbers: 11r�TC 1�,,�-1.�: y��,� l� ��1� J f.\t . ,.G' Y v �, � �. ,2 c r 5 ' o ¢— Were the police or law enforcement called? Yes �No ) Unknown (circle) `__. .-� If yes, what department or agency? Case#or repoR# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, c`lo,Jsest landmark,etc. Please bre as de ailed as possible. If necessary,attach a diagram. �� o 'i'l�[�. 1�dt 1v� 1'� �?�t �� D(n_S fi : ���/ `�'�� �✓ ���.!v[.:I��-I_.o��A �'k �{' Please indicate the a ount you are seekin in compensation or what you would like the City to do to resolve this claim to your satisfaction.�3�5 `�L �t ►�(nn �t�� -F�fz �'� i-'�.��. Vehicle Claims- lease com Iete this section ❑check bux i Your Vehicle: Year :Z d 1 Z Make V�I Ks v�%�,y z n Model < t ;ti. License Plate Number 11� J w i� State 1��Coloc g i ti�k Registered Owner ��v�l �,�.r v . �t Driver of Vehicle__��'L1ct�r,� fi,'l e v� �. t l Area Damaged �o.�s 1���— �',>��..-t- ��J� City Vehicle: Year Make Model License Plate Number State Color � Driver of Vehicle(City Emp�oyee's Name) Area Damaged In'u laims- le�tse com lete this section C]check box i F-Iow were you injured? What pan(s}of your body were injured? � Have you sought medical treatment? Yes No �--' Planning to Seek Tre When did you receive treatment? Name of Medical Prnvider(s): Address Tetephone Did you miss work as a result of your injury? �('es No When did you miss work? Name of your Employer: � Address Telephone'�`-----~-------- - --_ ___ � �CTheck here if you are attac�'1g more pages to this claim form. Numb of additional pages�. C r�`j �h�'l\�. 1hs3•�. G1�f L }��`ry,�3� f�yo'w� �f-'�� S:t.0�/iL� i►'�V'c�c c� ,. ��1c:s E. V'�+�.l�I tilt�F_� J � � �By signing this form,you are stating that all information you have provided is true and correct to the best of your knawledge. Unsigned forms will not be processed. . Submitting a false claim can resull in prosecution. Date form was completed � ,_,(� j � v �� T Print the Name of the Person who Completed this Form: _ ,N1�.�Y (, 1� �� ,r I l . " 1 ` ':: .... Signature of Person Making the Claim: ' � C--y - _ ,� � Revised February 201 1 `,` ' ' t � �, i 61V�z �/.���: ✓�2� ����VS ! ul�tJZ �' 2 �c ✓ �':! �1. ��,� L�c'� ^l�o,� ol Vl� � Y i T � , ' ,;i l.. � J��v� r�. ,1— tf v�c .2 S �r<c,< <�!(� `��e ��-1" In m I� J I�v��-t'1� ���.�h�. �, �� ��,��'� ,��J � !V . .�- i � ,. 11'�G1h� �'h�:v�.,.1 "�,,1Mi�S . 1'\2�: C.tY2 ✓t V � ����tn��i ��/.; v j 1 i \% a � G�.M.�L 1 1 80 East Highway 36 � � St. Paul, MN 55109 COUNTRYSIDE 65'-4g4-844' v�LKSWAGEN Fax: 651-484-8446 www.schmelzvw.com Cashiered Date: 03/21/201411:37:51 AM III IIII�IIN�IINIIINIII) SO#: 207617 Auth#: Page 1 Tag#: * Service Invoice Customer Copy * F,�t: Customer No: 6990916 Advisor: Shevawn Invoice Date: 03/21/2014 Tertn: CASH MARY MERRILI License No Odometer In Odometer Out Delivery Date Stock No` 101 SO WHEELER ST 719JWD 27618 27620 09/25/2012 920149PC ST PAUL,MN 55105 Year Make Model Model No Color Home:(651)699-0916 Bus: (000)000-0000 2012 VOLKSWAGEN JETTA 2.5L WGN AJ53S1 BLACK Vehicle ID No Selling Dealer SO Date InSenr Date Location Cell: (000)000-0000 Today:(651)699-0916 3VWKP7AJ3CM627553 COUNTRYSIDE VOLKS 03/21J2014 09/25/2012 Email:dnh@a.com Fleet# Request/Concern Type CSR# AmOUnt 1 0 CUSTOMER STATES passenger front tire is flat-- PZERO NERO 225/40/R18 ON HOLD IN PARTS TIRE PRESSURE LIGHT DIDNT COME ON UNTIL SPARE WAS ON- -PLEASE CHECK ALL PRESSURES 0 LABOR TO MOUNT AND BALANCE TIRE ONTO NEW RIM CPVW 426 25.00 1 281601361 RUBBER VAL C 1.94 1 1T4071498666 WHEEL C 276.00 Technician 6 MATT Cause: VERIFIED AIR LEAKING FROM VAWE STEM. INSTALLED NEW VALVE STEM AND INS�ECTED TIRE. NO DAMAGE TO TIRE FOUND. AFTER REFILLING TIRE,HEARD LOUD AIR LEAK. FOUND A SMALL CRACK BY VALVE STEM. NEEDS A NEW RIM. SHOWED CUSTOMER. SAYS SHE HIT A POT HOLE. ORDERED RIM FROM BURNSVILLE. Correction: REPLACED RIM AND MOUNTED OLD TIRE TO NEW RIM AND BALANCED. SET TIRE PRESSURE TO 38 . PSI.RESET TPMS LIGHT. ROAD TESTED: PASSED. _._........_...._.__._....__._. Request Total 302.94 2 0 SHE PURCHASED TIRES HERE LAST OCT.` __._._......------.._.__..... Request Total 0.00 3 NSD NEXT SERVICE DUE:@ 31 K MILES OF�OCT 2014 I Thank You Store Hours STATEMENT OF DISCLAIMER The factory warranty constitutes all of the warranties For Your Business! SERVICE SALES PARTS with respect to the sale of this itemldems.The Sellei hereby expressly disclaims all warranties either YOUf COfTlplet8 SdtISf8CY1011 IS OUf Monday-Thursday j Monday-Thursday Monday-Friday express or implied,inc�uding any implied warranty 7:00 am-7:00 pm 8:30 am-8:30 pm 5:00 am-6:00 pm of inerchantability or fitness for a particular puipose. #1 concem.If you can't 1'eCOf111712t1d Seller neither assumes nor authorizes any other Friday Friday Satu�d8y person to assume for it any liability in connection our service,or if you have any �:oo am-s:oo pm 8:30 am-6:00 pm 8:00 am-4:00 pm with the sale of this item/items. questions,comments,or if we can SBtU�day Seturdey ALL PARTS NEW ORIGINAL EQUIPMENT be of further assistance please 8:00 am-4:00 pm 9:00 am-6:00 pm UNLESS OTHERWISE SPECIFIED U-USED R-REBUILT COfltdCt US. 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O � RJ ._ .'J_ r"17 � -_ �L7 (n � -U Sl] (D � -6 �' n 7 �' v (D p ,�,, � � O s � i� � � � � � � � � �� m _ �' � � `G -' r ± , G�M.�+L 1 1 80 East Highway 36 S � St. Paul, MN 55109 COUNTRYSIDE 651-484-8441 Fax: 651-484-8446 VOLKSWAGENwww.schmelzvw.com Cashiered Date: 03/21/201411:37:51 AM III IIIIIIINIIIIIIIIIIIIIIII SO#: 207617 �Ic �ryice Invoice Customer Co�tv �k Auth#: Page 2 Ta4#: r 1 Fleet: Customer No: 6990916 Advisor: Shevawn Invoice Date: 03/21/2014 Term: CASH MARY License No Odometer In Odometer Out Delivery Date Stock No MERRILL 101 SO WHEELER ST 719JWD 27618 27620 09/25/2012 920149PC ST PAUL,MN 55105 Year Make Model Model No Color Home:(651)699-0916 Bus: (000)000-0000 2012 VOLKSWAGEN JETTA 2.5L WGN AJ53S1 BLACK Vehicle ID No Selling Dealer SO Date InServ Date Location Cell: (000)000-0000 Today:(651)699-0916 3VWKP7AJ3CM627553 COUNTRYSIDE VOLKS 03/21/2014 09/25/2012 Email:dnh@a.com Fleet# Request/Concern Type CSR# Amount -----._.._......_..._......_.... Request Total 0.00 4 NO NO OPEN RECALLS FOUND AT THE TIME OF THE APPOINTMENT ---------___..._.. Request Total 0.00 5 NAT NO ALTERNATE TRANSPORTATION NEEDED AT TIME OF APPOINTMENT. ._._...._......._...�._.__...__..... Request Total 0.00 6 0 CUSTOMER STATES AFTER RUNNING NUMEROUS ERRANDS SOMETIMES THE HEATER WILL STOP�LOWING WARM,AND START TO B�OW COOL AIR,TEMP IS SET ALL THE WAY ON Thank You Store Hours STATEMENT OF DISCLAIMER The factory warranty constitutes all of the warranties For Your Business! SERVICE SALES PARTS W�th respect to the sale of this item/items.The Seller hereby expressly disclaims all warranties either Monda Thursda Monday-Thursday Monday-Friday express or implied,including any implied warranty Your complete satisfaction is our y- v of inerchantability orfitness for a particular purpose. 7:00 am-7:00 pm 8:30 am-8:30 pm 8:00 am-6:00 pm Seller neither assumes nor authorizes any other #1 concern.If you can't recommend Friday Friday Saturday person to assume for it any liability in connection OUY S@NICe,or if you have any 7:00 am-6:00 pm 8:30 am-6:00 pm 8:00 am-4:00 pm with the sale ot this item/items. questions,comments,or if we can S2tUPd8y SetU�dBy ALL PARTS NEW ORIGINAL EQUIPMENT be of further assistance please s:oo am-a:oo Pm 9:00 am-6:00 pm UNLESS OTHERWISE SPECIFIED U-USED R-REBUILT COfltdCt US. Y-RECYCLED C-RECONDITIONED 3 � v, Dr n � � < �c� om � via-» � � �, o�-o .�. �. w � �. � < a� �. —1� cv� a �� � �p� c n� � m . � 0' �"� � (D � _. 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"�S � St. Paul, MN 55109 COUNTRYSIDE 65,-484-844' Fax: 651-484-8446 VOLKSWAGENwww.schmelzvw.com Cashiered Date: 03/21/201411:37:51 AM III IIII�IIIIIIIIIIIIII�IIII SO#: 207617 * Service Invoice Customer Co �k Auth#: Page 3 Ta9#: py Fleet: Customer No: 6990916 Advisor: Shevawn Invoice Date: 03/21/2014 Term: CASH MARY License No Odometer in Odometer Out Delivery Date Stock No MERRILL 101 SO WHEELER ST 719JWD 27618 27620 09/25/2012 920149PC ST PAUL,MN 55105 Year Make Model Model No Color Home: (651)699-0916 Bus: (000)000-0000 2012 VOLKSWAGEN JETTA 2.5L WGN AJ53S1 BLACK Vehicle ID No Selling Dealer SO Date InServ Date Location Cell: (000)000-0000 Today:(651)699-0916 3VWKP7AJ3CM627553 COUNTRYSIDE VOLKS 03/21/2014 09I25/2012 Email:dnh@a.com Fleet# RequestlConcern Type CSR# AmOUnt RED. SOMETIMES HEATER WONT BLOW WARM,EVEN AFT'ER ENGINE IS WARM, UNTIL SUDDENLY IT DOES. PLEASE CHECK FOR ANY FAULTS-IT IS WORKING PROPERLY RIGHT NOW. 87042599 A!C SYSTEM ADAPTION WPVW 426 Technician 6 MATT Cause: COULD NOT VERIFY CONCERN. CHECKED FOR TSBS: 2028678. CHECKED SOFTWARE LEVEL OF CLIMATRONIC UNIT THROUGH ODIS AND FOUND THE SOFTWARE LEVEL TO BE 0304. UPDATED SOFTWARE LEVEL SHOULD BE 0404 OR HIGHER. CLIMATRONIC UNIT NEEDS TO BE UPDATED. Correction: REFLASHED CLIMATRONIC UNIT WITH NEW SOFTWARE UPDATE 36C8. VERIFIED OPERATION OF ALL CONTROLS. Request Total 0.00 Added Operation 7 AIR CUSTOMER STATES THAT THE AIR BAG/SRS WARNING LIGHT IS ON,CHECK FOR STORED FAULTS IN THE MEMORY AND ESTIMATE NEEDED REPAIR. 01500000 VWOA DIAGNOSTICS,GUIDED FAULT FINDING WPVW 426 SEE THE TECH NOTES BELOW. Technician 6 MATT Cause: VERIFIED AIRBAG LIGHT IS ON. RAN ODIS[31 TU J-2 FAULTS. 1) 6101 E11 "SEAT POSITION SENSOR DRIVER'S SIDE SHORT." 2) 6101E29 "SEAT POSITION SENSOR DRIVER'S Thank You Store Hours STATEMENT OF DISCLAIMER The factory wartanty constitutes all of the wartanties For Your Business! 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FOLLOWED TEST PLAN. TEST PASSED. CHECKED FOR TSB:NONE. INSPECTED SENSOR UNDER SEAT AND FOUND WINDSHIELD SCRAPPER UNDER DRIVER'S FRONT SEAT. ASKED CUSTOMER ABOUT IT AND SHE SAID THAT SHE JUST PUT IT THERE WHEN INSTALLING THE SPARE. TOLD HER TO KEEP AN EYE ON IT AND SEE IF FAULT RETURNS. Repuest Total 0.00 LABOR 25.00 PARTS 277.94 SUPPLIES 2.50 SUBTOTAL 305.44 SALES TAX 19.98 TOTAL INVOICE 325.42 Thank You Store Hours STATEMENT OF DISCLAIMER The factory wananty constitutes all of the warranties For Your Business! SERVICE SALES PARTS W�h respect to the sale of this tte�tems.The Seller hereby expressly disclaims all warranties either Your complete satisfaction is our Monday-Thursday Monday-Thursday Monday-Friday express or implied,including any implied warranty 7:00 am-7:00 m 8:30 am-8:30 m 5:00 am-6:00 pm of inerchantability or fitness for a particular purpose. #1 concern.If you can't recommend P P Seller neither assumes nor authorizes any other Friday Friday Saturday person to assume for it any liability in connection OUf S81vIC@,or if you have any 7:00 am-6:00 pm 8:30 am-6:00 pm 8:00 am-4:00 pm with the sale of this item/items. questions,comments,or if we can SetUfdey SetUl'dey ALL PARTS NEW ORIGINAL EQUIPMENT be of further assistance please 8:00 am-4:00 pm 9:00 am-6:00 pm U-USED OTHERWISR-REBUILT D COI1t8Ct US. 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