williams KtC;EI!/ED
MAR 2 5 2�14
NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso a C L E R K
Minnesota State Statute 466.05 states that"...every person...who claims dmm�ges from any municipality...shall cause to be presented to the
goveming 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 wili not be contacted by telephone to clarify answers,so pmvide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written aclrnowledgement once your form is received. The process can take up to ten weel�s or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something dces 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 1'1��- Middle Initial � Last Name w� � � � a-� S
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address � 8� 3 �r 2�n n e,✓ �-V� .
City �0 S e u� <<�� State � � Sl
Zip Code 5 l �
Daytime Phone(��) G3 - 4�Cell Phone (6�� ) 71t7 _ 4d S� Evening Telephone(657 ) b33- �f`��C�
Date of Accidend Injury or Date Discovered 4���0/I�{ Time `7�00 a /pm
Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the Cit of Saint Paul or its employees are involved and/or responsible for your damages.
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I; 1G�n � ri l� d cn lRGe a n � t e �2.. aC G�o�e.�
l.i, r � h o �t!.� Cc U3 2 /Sl.
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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 ' t ❑My vehicle was damaged during a tow
y vehicle was damaged by othole condition of the street ❑My vehicle was damaged by a plow
❑My vehicle was wrongfully towe 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 yon need to include conies of all auAlicable documents
Far 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 far yourself before submitting your claim form.
O 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;ar the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs aze 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—nlease comnlete this section<�
Were there witnesses to the incident? No Unknown (circle)
Provide their�ames,addresses and telephone numbers:
a�.►.c�( 1�Ji l I i an� 1�„�r.�. � �.�✓e�/ a ve�„� . L� tpl�-�o k-(o y R Z
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.
(:l��iv,l a,n d- /-�-v�h,.. . �B�►G���.. ,-�� �w cn t��, a c� a� Scc%t�
Please indicate the amount you are seeking in compensad n or what you would like the City to do to esolve this claim
to your satisfaction. � � � a,c i a„� rt w(, � v��cc'�(�
� M � /0 /'/. �Lti m� /'� I'/'! �OCetnM
Wl�h �JL�r /ice� . /.l)l��fC.'1 .CO�m�P��l.t.Ge�/qp �i(/ti reP1G�r1 .ru-f r►+i�- G�Qw.�+'1 .
Vehicle Claims— lease com lete this section �� �check box if this section does not a 1
Your Vehicle: Year 2 DOS Make T NAFu Model_ <.n��
License Plate Number GZD /�-r/+ State MN Color 8Gi9G
Registered Owner 1,✓ �a:r�r a�d MreGraal o�rc (3wlL
Driver of Vehicle ar,l��/ Wrl r ' cclL
Area Damaged �arstn ct�s 5,�, �',en� �i,L,ri,.,:, a,,, Q/,�„m�,�,
City Vehicle: Year Make ' Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—ulease comnlete this section �'check box if this section does not applv
How were you m�ured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive trearinent? (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�.
By signing this form,you are stating that all information you haveprovided 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 O���a �/�
Print the Name of the Person who Completed this orm: �it e �n W I��c Q/�
Si atur f �Lf/2�L�Lt�i
gn e o Person Making the Claim: �1J
Revised February 2011
Brausens Repair of Arden Hills
Sub Estimate
1310 West County Rd E
Arden Hills, MN. 55112
Phone- 651-633-4100 Fax-651-635-9557
WWW.BRAUSENAUTO.COM
ESTIMATE R SERVICES Estimate Date : 03/20/2014
2005 Toyota - Camry XLE
ECK, MI Lic# : �6�E964� Odometer In: 0
1873 Brenner Ave Unit# : G Z� ��
Roseville, MN 55113 VIN # : 4T1 BE30KX5U500921
Home 651-633-4980 ---- Cell 612-708-0890
Cust Id: 383
Part Description/ Number Qty Sale Extendeb Labor Description Extended
NEW 16" 7 SPOKE RIM ' MOUNT AND BALANCE TIRE 30.99
MWTOY 1.00 451.15 451.15
215/60R16 V PRIMACY MXV4 BLK environmental fee 3.00
13397 1.00 168.66 168.66
shop supplies 3.10
II
Parts : $ 622.91 Labor : $ 33.99 Tax : $ 44.16 Total : $ 701.06
*********VISITOUR WEBSITE*********
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 vehicle described for testing and/or inspection. Express mechanic's lien is hereby acknowledged on above vehicle
to secure the amount of repairs thereto.
TEARDOWN ESTIMATE: I understand that my vehicle will be reassembled within days of the date shown above if I choose not to
authorize the service recommended.All Parts removed will be discarded unless instructed otherwise: Save all Parts .NOT
RESPONSIBLE FOR LOSS OR DAMAGE TO CARS OR ARTICLES LEFT IN CARS IN CASE OF FIRE,THEFT OR ANY OTHER
CAUSE.
SIGNATURE................................................................................................. Date......................................... Time.........................
Page 1 of 1 e5�».oi.oa
�
INSPECT NEEDED CONDITION �
CABIN AIR FILTER TIRE TREAD
AIR FILTER CONDITION PSI-IN PSI-OUT CONDITION
LIGHTS LF 32NDS
BELTS RF 32NDS
HOSES LR 32NDS
BATTERY RR 32NDS
W�ER BLADES SP 32NDS
FUEL FII,TER
EXHAUST TIRE SIZE
STRUTS/SHOCKS SPEED RATING
BALL JOINTS LOAD INDEX
TIE ROD ENDS
STABILiZER LINKS
Wf�EL BEARINGS ENGINE SIZE 2WD/4WD/AWD
CV BOOTS 2DR/4DR/XTD CAB
FLUIDS NEEDED CONDITION TRANS. AUTO MANUAL
WASHER A.B.S.FRT. REAR N/A
COOLANT OVERFLOW A/C P/S A/P
COOLANT PH VIlV#
COOLANT TEMP EXTERIOR CONDITION
RADIATOR
POWERSTEERING
BRAKE
OIL
DIFFERENTIAL-FRONT CAP ON OIL FILTER#
DIFFERENTIAL-REAR NEW STICKER #QUARTS
TRANSFER CASE OIL LIGHT RESET WIEGHT OF 011
TR.ANSMISSIOI�T #GREASE FITTIN6S
TECHNICIAN RECOMMENDATIONS
S � ! • �
� TOYOTA �CH VONDERHAAR -�- T
Service Consultont � O�o 1 �
P.O. Box 7005 • (320)253-2581
— (320)253-2581
1-800-892-0324 �c�'�r,�
Faa(320)259-1794
P.O.Box 7005,St.Cloud,MN 56302
w�w�vstctou dtoyota.com
��S,oMER No 5 g g 6 3
RI�C.t�ARD vONpERHq,qR 5130 �NO.�43 �( �18114 T�OCS1865F—"
RAE ANN WILLIAMS -�'� -PCK96� '"'�`s - --
1873 BRENNER AVENUE y �e:MODEL lOS,498 DESERT SND �-
ROSEVILLE, MN 55113 �5/ fOYOTA/CAMRY/4DR SDN XLE AUTO DEU��pp DELIVERYMILES
VEHICLE I.D.NO. O��1/OS lo
4 Z � B E � '0 ^ ^ J U 5 0 0 9 2 1 ��021 R NO PRODUCTION DATE
FT.E.NO.
P.O.NO. R.O.DATE
RES��,�PH��3-4980 86�12SP6�41-3106 COMMENiS 03/18/14
--------------
� ���-�""�""-- MO: 10549
------------------------------------
****�*�*�***�****�**��****��*,�.,t --------------
Any warranties on the products sold
* C ] CASH [ ] CHECK CK N0. [ � * TOTAL LABpR.,,, 132.60 hereby are those of the man�facturer. As
� * TOTAL PARTS.... 485.00 between this retail seller, ST. CLOUD
* TOTAL SUBLET... 0.00 TOYOTA and buyer, the product is to be
* [ ] VISA [ ] MASTERCARD [ ] DISCOVER * TOTAL G.O.G.... 0.00
* TOTAL MISC CHG. sold "AS IS"and the entire risk as to the
* L 7 AMER XPRESS [ ] OTHER * TOTAL MISC DISC 11.93 uali and erformance of the product is
* C ] CHARGE TOTAL TAX...... -61.76 q �Y P
*********�r****�**********�**** * 32.19 with the buyer. The seller expressly dis-
*�**���� TOTAL INVOICE ' claims all warranties, either express or
THANK YOU fOR YOUR BUSINESS!! a 599.96 implied, including any implied warranty of
merchantability or fitness for a particular
purpose, and the seller neither assumes
nor authorizes any other person to assume
for it any liability in connection with the sale
� of said products. This disclaimer by this
Sc;.B� .. '._ ��'. ' "." '�? -_ ^-S 0� 'h'
manufacturer's warranty\
THANK YOU
FOR YOUR
BUSINESS
. . . .
. - .
� -
. -
. �
�GE 2 OF 2 CUSTOMER COPY
[ END OF INVOICE ] 02:52pm
� �TOYOTA
�, OYOTA P.O. Box 7005 • (320)253-2581
�TOYOTA �s��o� � ' —��CIOr'1
� � T�iNO. � �NO.
�MER NO.
59963 �� uoNOF� s�.- : sr�� o� .is/14 Tocsis6564
►E ANN WILLIAMS �� �964 � 105,498 DESERT sN� ��K�
YEAR/ /MODEL `" DEL11BiY OA7E DELJVERY MILES �O
73 BRENNER AVENUE 05�TOYOTA/CAMRY/{�DR SDN XLE AUTO 03/31/05
S EV I L L E, MN 5 5113 VEHICIE I.D.NO. SELLING DEALER NO. PRODUC110N DATE
4T16E30Kx5U 500921 22021
F.T.ENO. P.O NO R� 03/1H/14
BUSINESS PHdJE-__.__-_._- �MINTS MO: 10549
;��3-4980 612-641-3106
-------------------•---
_________________________________ Any warranties on the products sold
hereby are those of the manufacturec As
PLEASE REMOVE DAMAGED RIM WITH NEW AFTERMARKET REPLACEMENT between this retail seller, ST. CLOUD
INSTALL ONE NEW MICHELIN WFIICH MATCHES THE SPARE MAKE 1HE TOYOTA and buyer, the product is to be
REMOVED DAMAGED RIM AND REPLACED WITH AN AfTER MARKET
RIM MOUNTED NEW MICHELIN ON THE FRONT ANO MOVED THE sold "AS IS" and the entire risk as to the
SPARE TO THE FRONT USED BESAT TAKE OFf TIRE AS EXISTING quality and performance of the product is
NEW SPARE with the buyer.The seller expressly dis-
tTS------QTY---FP-NUMBER---------------DESCRIPTION--------------------UNIT PRICE- claims all warranties, either express or
3 # 1 1 DT000-03097-MI 215/60R16 210.00 210.00 implied, including any implied warranty of
; # 1 1 ALY69-475U1-0 05 CAM ALL 16X6.5 225.00 225.00
3 # 1 1 NP MISC PART 50.00 50.00 merchantability or fitness for a particular
JOB # 1 TOTAL PARTS 485.00 purpose, and the seller neither assumes
nor authorizes any other person to assume
JOB # 1 TOTAL LABOR & PARTS 515_60 for ft any liabil'�ty in connection with the sale
-------------------------------
-------------------""""'"'"'""""""--��� � � of said products.This disclaimer by this
_. � _
� CUSTOMER REQUESTS 4 WHEEL ALIGNMENT seHer i� no way effects the terms o e
PERFORMED A 4 WHEEL ALIGNMENT ADJUSTED FRONT LEFT manufacturer's warranty.
AND RIC�iTIREARFTOE AND BCAM�ERJALIGNMENT INASPECSLEFT
RTS------Qn---FP-NUMBER---------------��RIPTION-------•--�-#--�-TONAL PARTS 0.00
--------------------------------------------
,o� # 2 TOTAL LABOR & PARTS �02.0o THANK YOU
� � �.
PERFORMED AN WXPRESS WASH FOR YOUR
UtTS------Qn---FP-NUMBER-----•---------DESCRIPTION----•-"'-� # 3 TOTAL PARTS 0.00 BUSINESS
JOB # 3 TOTAL LABOR & PARTS 0.00
•---------------------------------------------------------------
---------------
------------•--------CONTROL NO---------
[SG-•---CODE--------DESCRIPTION---------- 11.93
)B # A A1 ENVIRONMENTAL/DISPOSAL/FEES -3.06
)B # 1 D2 lOX TOY LABOR CWPON -48,50
)B # 1 D4 lOX TOY PART DISCOtRiT COUPON -10.20
�g # 2 D2 10X TOY LABOR COUPON TOTAL - MISC -49.83
. � .
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