Lenhart_ __ _ _ _ _ -- _ �EC�I��p �
MAR 2 5 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Min�����E�K
Minnesota State Statute 466.05 states that "...every person...who c/aims damages from.any municipaliry...shaU cause to be presented to the
governing body of the municipality within 180 days afier 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 WE5T KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
AA i�..4..e.�t� � �` s I
First Name 1 V l _ Middle Initial Last Name L 2,h���'t
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Company or Business Name
Are You an Insurance Company? Yes/ i�o If Yes, Claim Number?
Street Address �S 3 3 S�..e � d.o h S-h-�c�"
City st ��+�-1 State �N Zip Code SS�I �8
Daytime Phone (`�Z ) 24�-92Db Cell Phone( S� - Evening Telephone( ) -
Date of Accident/Injury o Date Discovere � ��?9� I `(' Time 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 employees are involved and/or responsible for your damages. � _
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'�,L Grur 1JA�5 '�h� {o St�� w Is.v� b wt' -�'urti�� w�o i�,. i'�s- �u't' o`. Ce1w0• A.rs�r �r�" �F il.a'�
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Please check the box(es)that most closely represent the reason for completing this form:
O My vehicle was damaged in an accident '�My vehicle was damaged during a fow
❑ 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 WII,L 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
�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
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_. . - � .. -�. _�,. 1
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease complete this section
Were thebe witnesses to the incident? Yes No Unknown (circle)
Provide t�eir names, addresses and telephone numbers: �I.e. � �,.,as -tvw�9 �� -�c �.�dl�� o F �.a n��l�i': �l ��
112J i�n ��a.►+�-�n u� S P r✓��e c�.r. �,�t G<+ tn �. co k e-i+.b� o� �I.c t:L r o ds� f k�P;
(S6S �}c�.w�ltwL,�Fd Ni -S� �4�.-l� {j'Slog. �osl'b S-S�{3`�- `�.
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 park or facility,
closest landmark,etc. Please be as detailed as possible. If necessazy, attach a diagram. "f1.� c.s.� �►a s -{�,wc�
�r;,vn '�^t W ta.l�e�+, I✓1 �rn� OT Oc�r Y�ON.CC I�33 $�t�O�h .S�hrlL}�. �r' �dw1 � �5��'D�.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
toyoursatisfaction. �•/e are s«k: r<i �ser,c..t FaY �l..e..' e�r w�'PN 'fZJ-�'0 5 �0.1, Y ass���d
w.� rt��QU�^-A i'�t h,��,,�( -1'L.t a� e,,.�,,.•.r.�. 'ra�i^� co�.�.�.u,c a�'i o n r[-q LL,tS-�e-� i f ��F 8 b• 9 S.
[Ou..+e� t�e,YOd a„�d��.� zv,,,��e�-ol l�3• 't4 � lv.b r IS3• pO� e�.\���„ti.t.x ?Q.95•�
Vehicle Claims-please complete this section ❑ check box if this section does not applv
Your Vehicle: Year a2oag Make Sw-bar�- Model 0�+6.�.E.J<
License Plate Number Vrj£ 6 6D State I�N Color _�1 cL
Regi stered Owner c 4.r t s+:�r l,.e.n l,.a r fi
Driver of Vehicle
Area Damaged od 5 b2,.� �,..r; �,a
City Vehicle: Year Make odel
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injurv Claims-please comnlete this section ❑ check box if this section does not anplv
" - How-were y�u injurCd? -
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
pv�a rt�+P�"
[�Check here if you are attaching more pages to this claim form. Number of additional pages 2. . o^� p�,i,o
By signing this form,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 _ �J'` ��-� � ``�
Print the Name of the Person who Completed this Form: M`���`���� Lehh"°`r� a'"� c►-r�S 1-e--"-�`r'�
Signature of Person Making the Claim: � �,�(
Revised February 2011 /�,��.
HAMLINE-HOYT SERVICE
1565 HAMLINE AVE N INVOICE
ST PAUL, MN. 55108 25141
Phone-651-645-5434 Fax-651-645-1548 Org. Est. #041443
INVOICE Print Date : 01/29/2014
LENHART, MICHELLE, CHRIS 2008 Subaru -Outback-2.5L, H4 (150C1)
Lic# : - MN Odometer In : 40967
, Unit# :
Home 612-296-9206 Vin# :
Cust ID : 5440 Hat# : Ref# :
,
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��� .. � . , , F A ��r.��.,� d �. �.,,,�� �� ��:� ..'� �.�' ,.,� '' �'�""�� _
Outer Tie Rod End Remove and Replace Both Inner and Outer 153.00
401-2052 2.00 75.26 150.52 Tie Rod Ends
Tie Rod End Inner BOTH INNER TIE ROD ENDS WERE BENT TOWARD FRONT
OF CAR. BOTH HAVE METAL SCRAPE MARKS ON THEM IN
401-2166 2.00 51.74 103.48 THE SAME LOCATION.
Front Brake Pads REPLACE FRONT PADS AND ROTORS 102.00
D929 1.00 59.56 59.56 REPLACE REAR PADS AND ROTORS 102.00
Front Brake Rotor ALIGNMENT 79.95
PRT5657 2.00 59.16 118.32
Rear Brake Pads
D1114 1.00 59.56 59.56
Rear Brake Rotor
PRT5752 2.00 42.60 85.20
Shop Supplies 14.99 14.99
I
Org.Estimate 51,070.73 Revisions a 0.00 Current Estimate $1,070.73 Labor: 357.00
Parts: 591.63
Sublet: $79.95
Sub: 1,028.58
Tax: 42.15
Total: 1,070.73
Bal Due: $1,070.73
[Payments- ]
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees permission
to operate the car or truck herein described on street, highways or elsewhere for the purpose to testing andlor inspection. An express
mechanic's lien is hereby acknowledged on above car or truck to secure the amount of repairs thereto.Warranty on parts and labor is one
years or 12,000 miles whichever comes first. Warranty work has to be performed in our shop&cannot exceed the original cost of repair.
Signature Date Time
Writlen By:L,Kevin-Technicians:Please Select,Technician;M,Dave Page 1 of 1 Copyright(c)2014 Mitchell Repair Information Company,LLC invhrs 03.18.2011 JD
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