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Tighe �c�i��D MAR 2 5 2�14 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota CLE�K Minnesotn Stn�e Stntute 466.05 stntes that "...evei��person...whu claims damages fi�om m�y municipnlih�...shnll cnuse to be presented to�he governing bodv of the niunicipaliry within 180 days after the alleged loss or i�yi�ry is discovered a nolice slatrng the time,pince,nnd � circumstances thereof,and the amount of comperlsnlion or otlier 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 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 ��.s a,T+ Middle Initial_ ✓ Last Name T/ C H � Company or Business Name Are You an Insurance Company? Yes No� If Yes,Claim Number? Street Address ��3 ��/�j. �v�, Cit L.i tt/e __�a.�+�.o�a. State /�1 N Zip Code SSi i � � Y .Z�� Daytime Phone( ) - Cell Phone(es,) - '�+�Lo-9Evening Telephone( ) - Date of Accident/ Injury or Date Discovered Md..�� i -r o i�Time O�3 S am/pm Please state, in detail, what occun�ed (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 your damages. :� w a. 7�'0 .� � �u•.s �o a�.�.�t � � o r� �-t a..-e L, // w�mn -T ��. �J- ir. sf"_ dv� i fG � �^ * L.r.,,-✓e.-s;�.. �✓2 �/(na � �6/oe/c 1 -� s�...St , e� to. �`�,e � / ` , 7f �.e r,' _ r� r- S i d e ..Z- S 7r"'a� .f+ � �i�i c� fi�.� r, tr .�� _ 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 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 y^�� nPPd to indude copies of all applicable documents. � For the claims rypes 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 rewrned. Page 1 of 2—Please complete and return both pages of Claim Form a I _ ' . i - — — � I i � Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—qlease complete this section 1 Were there witnesses ro the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or]aw 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 facility, closest landmark, etc. Please be as detailed as poss ble. If neces ary, attach a diagram. i 6 0 �6/o s�c �d,.tt ui�i ✓t�-S�fy /-\�/� � �.ir.� �GOiv�S /LJe.tAi�t-a / Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. �e S 7` fa r�b/e,c� r��ti-. a.� o.-,e ��e . Vehicle Claims—ulease complete this section ❑ check box if this section does not apply Your Vehicle: Year �o i� Make �5��..rb�.�-.i Model 7 .- License Plate Number Get� H YT State ��/Co or �e�� L�e�� Registered Owner ��,sdh � T"� G H � _ � Driver of Vehicle S�.sa... �/ . �� G H c AreaDamaged� asse.-.oe.- s��e 1 ��-a.�� w�es/ .-.�.,,, a.,� �ba.c.�c f,:-e City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniury Claims—please complete this section �heck 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 � . M By signing this form,you are stating that all information you have provided is true and eorrect to the best of your knowledge. Unsigned forms will not be proeessed. Submitting a false claim can result in prosecution. Date form was completed _�_L at`� , �� `�` Print the Name of the Person who Completed this Form: S�s � � � �� '`{C Signature of Person Making the Claim: Revised February 201 1 , � ' � , . j . : � I I � , � � � i Luthe White Bear �-++ Acura Subaru ++ �CUI=�� SUBARUo 3525 No. Hwy. 61 • WHITE BEAR LAKE, MN 551 10 651 .481.7000 • Fax 651.251.0458 www.wbacura.com CELL: 651-247-4609 TAG N INV(�C�U�VjE / INV ICE ADVISOR us�.14 14 U�S 0910 °�ST°MEa"° 52386 HRISTOPHER 7 BOEH 568 �756 I.ABOR RATF ��oFNSE MILEA6E �3�165 c��o�HERRY P �� USAN J EAN TIGHE �p� °E""F�"""ES 10 73 ALLEN AVE Y�'��1�/ZMpREZA/5DR WGN 2.OI PREM DE��/1T�/12 LEF NO. PRODUCTION DATF ITTLE CANADA, MN 5 5 117-12 89 �,;�Fe��NO� P A p 6 6 C H 2 2 5 1 6 2 �� F.T.F.NO. P.O.NO. R�T�13/14 ighe001@tc.umn.edu Mp: 23168 1L �y�� 6MNL ADI�RESS R F CF � � �iSWE'r'�Ei JF Z�I F�� .. . . . ��=��-26i7 ,�-G� ,- �.,_ ._...:.... -•-••-•-- Any warranties on the ptotlS�Cts s61c��her0by are tflose •.�.«-:�i....:.�.....:..�""'•'..."'........�... . , .,..�_..-.«, af;'the,m��ufacturec As betwAert this retaii 9eller, WHITE BFAR ACURA, SUBARU, ISUZU and Buyer; CUSTOMER STATE$ THA7 SHE HIT A POTHOLE ON PASS $IDE FRONT AN the product is to be so�d"AS�s"and the enHre�isk as D NOW THE lOW TTRE LIC�HT KEEPS COMING ON to the qua�ity and Pertormance ot the proauct is with IN$PECTED SUSPINYbN AND TIRE AND RIM FOUND NO DAMAGE thebuyer.7h2selletexpresslydisclaimsallwarranties, CORRECTED TIRE PRE$$URES AND CLEARED CODES AND f�RS7 DROVE ,�,��hrentyXOt merchan a�ii ty or ti nU slsgor�a part Plu a�r ----�ES�RIP7ION•-••••---LI$Y PRICE-�NIT PI�ICE- purpose,and the seller neither assumes nor autho�izes ARTS----•-QTY`•-FP-NUMBER•�----"""" DISC WHEEL A 359.96 359.96 359096 any othe� person to assume focit any tiabllity in �g # 1 1 28�.11�J0�� 12.CJ9 connectla� with the sale ot said producls: This OB # 1 1 28194SC000 " 7PMI$ $�EM AY discleimer by thls seller inno way effects the terms ot 12.59 12.59 ' JQB # 1 TOTAL PARTS 372.55 the manutacturer's warranty. F JOB # 1 TOTAL LABOR & PARTS 402.50 ----•-------- - ____________________________ __________________________________________________ cl�iedule INSPECTED �RAKE LI�VINGS AND FOUND CONDITION''f0 BE COOD. INSPEC7ION PERF�Rh�E� On•lineiervicescheduiingatLatherAuto:com ARTS--••••QtY`..FP-NUMB�R•-•-••-------�•DESCRIPTION..-.----•LIST PRTC�-UNI1' PRICE- JOB # 2 TOTAL PARTS ' 0.00 JOB # 2 TOTAL LABOR & PARTS 0.00 --------. _ - A INSPECTED 7IRE TREAD DEPTH AND FOUND CONDITIONS TO B� GOOD. : INSPECTION PERfORMED ARTS-••---QTY•-•FP�NUMBER-•..:.....:....DESGRIPTION---.�...•�JOB # I3ETOTAL PARTS ` 0.00 � 0.00 JOB # 3 TOTAL UIBOR & PARTS__ _ . Cash for your vehicle. ---•-•--•--------------•----------------•--- --•--..... ..................... Your car.could be worth more than you think!And we91 buy it!(Even if you don't - BATTERY HAS BEEN TESTED AND IS IN GOOD CONDITION AT THIS buy from us). We'll quote ANY vehicle, TIME. regardiess of condition..If you accept, REPIACEMENT NO1' NECESSARY. you'll walk away with the cash. You'll ARTS--••-•QTY---FP�NUMBER•••-•-•-•••--••DESCRIPTION-•••---•-LIST PRICE-UNIT PRICE- never'find afaster,simplerorsafer way JOB # 4 TOTAL PARTS 0.00 to sell your car.Visit our Sales Depart- JpB # 4 TOTAL LABOR & PARTS 0.00 ment for your no obligation appraisal or •--—------�-•-- -•--•--•---------------•--------- -------•------ learn more at�UTH�RAt 1T0 COM ...-----•-•-•-------••---------- *FX D_��-.�VAG�HIGI.�S PERFORM MULTI-POINT VEHICLE INSPECTION. SEE ATTACHED COPY. ARTS•--•--QTY-•-FP-NUMBER--------------•DESCRIPTION----'"-'��jOB #R15ETOTAL PARTS 0.00 ��U� ,� -----..._.--•..................JOB # 5 TOTAL LABOR & PARTS^...._.__.0.00 S U BA R U� --•------------------- ---------•---------'� IED .O.G. & SUPPLIES-------•------•---------•-------------------- 50.00 OB # 1 FREIGHT (PAFtTS) T07AL � GOG 50.00 ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SP�CIF THANK YOU! WE APPECIATE YOUR BUSINESS PAGE 1 OF 2 CUSTOMER COPY ICONTINUED ON NEXT PAGE] 09:05am 2 -.:: -_ __-y��.__ ==�-"---"---- - - �-_-�-.. d�i�..�y-,u., _ .,�_,_, .,.�.�---"-°�`=-�'`�-- _ - _ . = ,. , - - -, -�-�-f-_-- __ _ _ f Luthe Wh i te Bea r + �++ Acura Subaru �� CU�� SUBARUa 3525 No. Hwy. 61 • WHITE BEAR LAKE, MN 551 10 651 .481 .7000 • Fax 651.251.0458 www.wbacura.com CELL: 651-247-4609 `�S'°""�R"° 5 2 3 8 6 �DVISOR 7AG NO INV C D E INVOICE HRISTOPHER ) BOEH 568 6756 ��`�4/14 UCS 091U LABOR RATE LICENSE MILEA6E COLOR S USAN JEAN TIGHE 23,165 P CHERRY P � 73 ALLEN AVE R EIMOQE4 DEL E Yp T DELNERYMiLES �/sku�`sa�u/zr�p�EZA%5nR w�N z.oz PREM ��/�.6/12 10 ITT L E CANADA, MN 5 5117-12 89 VEHICLE I NO. I LER NO PRODUCTION DATE J F � G P A D 6 6 C H 2 2 5 1 6 2 �b��(� F.T.E.NO. FO.NO. �O�T�13/14 ighe001@tc.umn.edu qb�FN-Fpi1('NF_�� l,liFSS��yE,L1ll1 F-MAILADDRESS M�: 23168 .L V J iJ ; ..----..--=.i...........:..:. ....c c`--..c+.•...-- o s .�....,.� �� : Any warrandes on lhe products Sold hereby ate tho'se .k .�i3 � USTOMER HE12�BY ACKNOWLEOC�S�RECEIVI�NCy ��- � �' ¢_ : ot tne.rrianutacturer. As�between tnis retan�sener,� `� ORTC�INAL ESTIhIATE 0�� 5510� 00 (+T�1X) � ,. � _ � _;'� � � wwir��Eap��acuwa,s��nrau; i�uau ana�euyer,� O7ALS-•.--•---...-••--•.-.•`.""'`_:......'.. ..... ...... .,,....- ..::.+.•" the produet is to be sold"AS IS"2rtd the entire'risk as to ihe qu2lity And performence of the product is with, **,r*****�rx*****,r**�*,�x********�********* ** TOTAL IABOR.. 29,95 �he buyer.The seller expressly disdaims ali warranties,' ir * TOTAL PARTS.... 3�Z.55 either express of implied, Mciuding any implied ['] C/�$N [ ] C�GE [�-ISAIMC warranty of inerchantabilily or fitness for a particular * +� TOTAL SUBLET... 0.00 p�.�ose,at�d the sel�er neltRer assumes nor authorizes * [ ] AM�X [ ] DISCOVER' [ � CHECK # *"" - ?OTAI 6.0.6.... 50.00 a�y other perso� to assume for it any Ilabiliry In **x��r*********,�x****�*r�**�********+�************* TOTAI MISC CHG. 0.00 connection w�m tne saie ot said products. This .�.�.rA� MIS�'�ISC �.�� discfairr7er kay this seller In no way eNecis the tetms of E ALSO DO PAINTLESS DENT REMOVAL HER� ON SITE, ASK YOUR' 707AL TAX..:... 30:12 themanufacturer'sWarrarltY. ERVICE CONSULTANT FOR DE7AILS. 70TAL INVOICE$ 482.62 HANK YOU FOR YOUR RECENT VISIT TO WHITE BEAR ACURA, SUBARU ��'� b ISU�U. WE HOPE YOUR EXPERIENCE WAS EXCELLENT AND ALL -� ERVICES WERE PERFORMED TO YOUR SATISFACTION. YOU MAY ALSO ECEIVE A SURVEY FROM TH� MANUFACTURER 500N, PLEASE TAICE A om�ineservlceschedu�ingat�utherAuta.com OMENT TO FILL`IT OUT ANd SEND IN. IF YOU HAVE ANY`QUESTION5 ;�rf , ;'' R COMMENTS PLEASE CALL 651-481-7000. '# " ` •� ' k _ _ ��'rK7 � � � ij f }� .��'. . . . . . � . y( . . � P. � { t 1. 3� # ..� €� Cash for your vehicle. Yo�r ca�could be�vorth more than,yo.u;. .�r F�, �� >�� - � ,� " - - _ �: think!'Antl=w�'li buy it!(�ven if you don'{� � �? ,�. �� s r F � �'��; t=s � buy fr�m us). We'll quote ANY vehicle, �� = ? ; �? F: � � regardless of condition. if you acoept,� �3 4 a s you'll walk away with #he cash. You'll ;: 1 � ' never find a faster,simpler or safer way to sell your car.Visit our Sales Depart- ;� ' t • "�•+ ment for your no obligation appraisal or leam more at I UTHERAUTO COM 'EX�LUDES SA1 VAGED VEHICLF� �� SUBARU� ALL PAFiTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED THANK YOU! WE APPECIATE YOUR BUSINESS PAGE 2 OF 2 CUSTOMER COPY [ END OF INVOICE ] 09:05am i-- ,_ _ _YP; ; .. II I � i L.uthe White Bear �--++ - � Acura Subaru +� �CU�� SUBARU� 3525 No. Hwy. 61 • WHITE BEAR LAKE, MN 551 10 651 .481 .7000 • Fax 651.251.0458 www.wbacura.com CELL: 651-247-4609 ADVISOR TAGNO INVOC DAT INVOICEa CUSTOMERNO. ��HG HRISTOPHER 7 BOEH 568 1234 b�3/�7/14 UCSS 1�98 V LABOR RATE LICENSE MILEAGE COI.OR USAN J EAN TIGHE 23,220 P CHERRY P �1�� R MAKE/MO�F l DELI E p7 DELIVERV MILES ZO 73 ALLEN AVE ��SUBARU/ZMPREZA/5[�It WGN 2.OI PREM ��/�.�/12 ITTLE CANADA, MN 55117-1289 vEF�i��Fio�i�--- � s �er+Na aaooucnoNOnTe J F 1G PAD66CH 2 2 5162 ��"�� F.T.E.NO. P.O.NO. R.O��T��/�^ ighe001@tc.umn.edu � RF�! CF P 1 1�$I ESS � E 7 � 6MAll ADDRESS MO. 2 3 Z 2O �i��-b��-267i ��-��-�Z6� ..---•-.__.. ,_..,_.................................................:.:. q�y warrantles on the produCts sold hereby are,those of the manufacturer. As,between this retall selier;, CUS70MER STAT�S. RIGFI7 REAR'TIRE WENT FLAT CH�CK AND ADVISE wH�7e e�AR/+CUA/+,SUBARU,ISUZU and buyer,: � � lhe��product Is to be sold"AS IS"and�the entlr0 risk as' $�E Nj$TQ{ZY to the qualityand performance of the product iswithi TIRE HAS SMALL NICK IN SIDE WALL : ,. ' tnebuyer.Thesenerexpre�slydlsclaimsallwarranties, REPI/10E' RIGHT R�AR TIR� either express or implied, tncludin9 any lmpiied warranry of inerchantabilfry or fitness for 0 particular ARTS•-'••-Qn'-•f P-NUMBER•••-�--•---•••-DESCRIPTION-•-••----LYST PRICE-UNIT PRICE- purpose,andlhe seller neithar assumes nor authorizes OB # 1 1 9321� P205/50R17 YOK - 190.00 190.00 190.00 a�y otner person to assume tor it any liability m JOB # 1 TOTAL PARTS 190 i OO connect�on wtth the sale of said producisi tMs dlsclaimer by thls seller in no way effects the terms of the manufacturer's warranty. .._:...................'...................--' ----.......---... ....................., ... I JOB # 1 TOTAL LABOR & PARTS 210.00 STIMATE....................'•---.....-----.......;•--......-:-•.....-•----......... USTOMER HEREBY ACKNtlWLEDGES RECEIVING _ (�hedule ORI6TNAL ESTTMATE OF 5220.00 (+7AX) ' OTALS•.-- .................'-----......_-.......--•---•••-•-------...-•-- - • . Omline service scheduling af LutheiA�ito;com �r*�r******�***********************�****�x*�r**,rh*** TOTAL IJIBOR.... 20.00 * [ ] CASN [ ] CHARGE [ ] VISA/MC ** TOTAL PARTS.... 190.00 * : ** TOTAL SUBLET... 0.00 * [ ] AMEX C ] DISCOVER [ ] CHECK # ** TOTAL G.O.G.... 0.00 ***,r**,r****,r*****************,t*x�*****�rrrx**,k,Y,�* TOTAL MISC CHG. 0.00 TOTAL MISC DISC 0.00 E ALSO DO PAINTLESS DENT REMOVAL HERE ON SITE, ASK YOUR TOTAL TAX...... 13.55 � ERVICE GONSULTANT FOR DETAILS. TOTAL INVOICE S 223.55 � HANK YOU FOR YOUR RECENT VISIT TO WHITE BEpR ACURA, SUBARU ND ISUZU. WE HOPE YOUR EXPERIENCE WAS EXCELLENT AND ALL ERVICES WERE PERFORMED TO YOUR SATISFACTION. YOU MAY AlSO -�< ECEIVE A SURVEY FROM THE MANUFACTURER'SOON, PtEASE TAKE A OMENf TO FILL IT OUT ANI� SEND IN. IF YOU HAVE ANY QUESTIONS Cash for your vehicle. R COMMENTS PLEASE CALL 651-481-7000. Your car could be worth more than you thinkl And we'il 6uy iii(�ven if you don't buy from us). We'll quote ANY;vehicie,' � regardless of condition. If you accept, you'll walk away with the cash. You'll never find a faster,simpler or safer way to sell your car. Visit our Sales Depart- ment for your no obligation appraisai or learn more at y�ILIHERAUTO COM *EX�CL��ES SALVAGED VEHIG ES �� SUBARU� ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED THANK YOU! WE APPECIATE YOUR BUSINESS PAGE 1 OF 1 CUS70MER COPY [ END OF INVOICE ] 10:11am