Dunkel RECEIVED
MAR 31 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�.p��t�LERK
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be 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,nnd
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. ff 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 acl�owledgement once your form is received. The prceess 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 sometlring 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 IV1QttI1eW Middle Initial F Last Name Dunkel
Company or Business Name EQSt Side Llquol' StOt'e
Are You an Insurance Company? Yes/l�{ If Yes,Claim Number? X
Street Address 1361 E MarXland Avenue
City St Paul State Zi Code 55106
mai : eastsidPeliquor otmai .com
Daytime Phone(_) - Cell Phone(.�.��7-9934 Evening Telephone(_) -
Date of Accidend Injury or Date Discovered 3/24/2014 Time 2:15 am/p�
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.
I was traveling under the posted speed limit (30mphJ on White Bear Avenue coming from Marylnnd Avenue on my
wn�to the M�lewood Mall area I wns going to visi� my accountnnt und then return mv lonner car to___KLINE Nissan
alo"� F{�qr 61 White Benr Avenue is n minefield of dnma9iC� eotholes thro�tah�iLl�Cty arPna �ncl��d�rw he nren where
� . I no
.
��'��������¢d}���r��s$Y►�Rl�ie reason for completing this form:
O My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
�I 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 pmperty damage—please specify
❑ Other type of injury—please specify
In order to process your claim j�::ueed to include copies of all apnlicable 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 aze encouraged to keep a
copy for yourself before submitting your claim form.
Ql�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
Tb4 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 resWt in delay in the handling of your claim.
All Claims—please complete this section
Were there witnesses to the incident? Yes I�6 Unlrnown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes 11�6 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 necessary, atcach a�iagram. Street side of Taco Bell
on Nebraska � White Beair Avenue �Across from Wulff Funeral Home/1485 White Bear Ave.)
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. �65 from L�ther Towina for switchina out flnt, damQaed tire for the sn, nre &
OTAL=
e assistant service manager re erre to it a a g s w � e t e repair mvoice states it ns n m s ns �266.94
Vehicle Claims please complete this section ❑ check box if this section does not aqv v
Your Vehicle: Year �n13 Make�icaen Model�Jtimn
License Plate Number State#�Color c��.,�Q�
Registered Owner KI T iSSan (Inener cnr whilp t�v SUV wns� reneired�
Driver of Vehicle �� i��- � �---�
Area Damaged�r_ ont nassPnnPr tire
City Vehicle: Yeaz Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims ulease complete this section ❑check box if this section does not apply
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�.
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 3/26/2014
Print the Name of the Person who Completed this Form: Matthew F Dunkel
Signature of Person Making the Claim: � �GGh'�¢X
Revised February 2011
v,rs��v. #�r� � i�'t` :�N aa ��..
„.�J�iw�, ��` �n� �. r,�?, � r,�. �: ,.3 �"�:
r,
.FTt-'✓���7''�F; �'.a � ' a
��1� �
*0.��� t H =;
L $ty t, {t��� � ,
�� Add� F� ,+r., � �_
�
��t� r��: t.� �..
L� PAt�� 1 � "
;�
�e I�4/�A. ; '`°�-
��`� , S�RV'10E A1'?1!'#S�< �m .
�;��_, _ y�r
L� k�`F�- . ^ .� � . ' .Y ..°C'� ..'_
. a
' Ai�l1 �il\7 . .Jf7�D ��.7� . . Y s,�..... � .
'� ��El�' �'
� � ��� � 8: �4 �4� � .tt '.��Y��a
� REAf1v OPFtONS� S K:N4 i 2 8 7 t3€,Ft:�9t��D? �x�
�
�� ;� �
�� 24MAR19 YF� �-`��` *'w ?i�k
, � �{�=-�PE HC�C2R�� � � - ,- .�=
. .. w%,L�f"aT`.,,�.. 1d�"sT
, `�t'�.Ft� RF3PAI]2- C:FiEc;,iC 'TI12E IIt �`HE TRLXltiTK_ It�I�7, �' ��8 Y�
�a t +�:°��k��L�I? 'i"IRS �
�{,' ,"�R� �?�RM TSRE REFAIR �����"
;�.��7 CM 29�.�3�
�: ,{�'��R-{}2923 Cfl23TINENTAI� Pi'� _+aS.E}Q 365:t}#�
° ,, i 'T'� Z`�I2� DISFC3SA� 2.�0 �.�tI � '
` ��'7.5fl LAr'30FZ: 29.95 O"�'?:E , .�� x�.:'�r'il., £,:�I� A: �.�"�«� ���;�°'�:
���= � '' ' � � � �,�ssrrya� -�
9�.�• R.£�FIaPi�"� T{F TIRE - a�'IDBWALL :�fii.�:t�^sE iv �x' :'I�c.. � it�i��i SLASe�i "� w "'�a' �
,�y a.waa� ��,.
' *#a�*�***�!*#t##**�k*#iF*i f1'#A 4 i*f t i t frt k ir#aY*##fri#ii*#tYY►#r ,�{, , ; ��f��p.„,�,�
�h
i'a���: .�t�� f 4�.''��.Y .��:... . ...�: , . . �s
;�'i`i'����`-,�F�Ot7 CHTaRGE FGR R�PAZi� i�Ra:✓*�� ��'�,-�' `�"�i"��`
TH�1:{ JO:.T FOR i3XJ�,� "v� fLiNE NISSA!!+� �".� -���
kAVE . C�:�":�'�'.�'b"?`S ^� C:t�JiERPIS PL�SE ��vv*-�
���- . :
;:�4 ,: OiIR S 32�iI�� "�'.AD:A��R S':'��'�+'E MCMAHi7I� +� 3`�"���. � �,
;.
n�� �; _ � �
� r x � ...� ss�x'urxv .-, � r
��g ' c c�=-'ax�. ��`� :
.
��eTc � -� - =r'xm �� a� �'t��b'
T � S��YnXC7 � � �'�� �'�
� r . . �� � , � � � o..
v
y' c ° Xt�7 " .�+ � � �v �, .� ;y�'r.�,� 3' a� �` [,.-..,
o:� XA o.+•s r �:x...
� �� r ."'�.a X w�r� Q l��'�7� -� � .
� � `��'a �'. a
`,,: �J . d Z X ���•=..Lt ' � ;.� r ,;�,'
�, � nw e
t A C T �v.��� � � ',-
��,. V-." V ano, qC �
3'"; ;� "a; Y! �.�� � �" Q � � -
r, . .. N W r G . ,�. ...;�...�,
0
. � .°.. GA g�� �J
� � ,� m� � �:
N
M . �1 :r
�.;,� � N..#� � . y��... .�
"O y�y
� �„ �� QY Vw . N . S.F .
ry�
� q
�r ; �� >;
- � �� �� �
-- aT,r. '��,x ;�p�,� 5 a �.ti".� ��,
�-.:� � •����',.�. . '.is��+�.�F.. ,�',���i�.I��" _�� A
� . �1�. � � � � �'��'
� N� �[tT�1� Z��!L� frtl! t�E S�.�,.
>
� �-TN6 hsrebY'��'�Y
, LL ` �����f�l���
�� �}�
l _ � �
$ �N�r�`
r��d j��.l fi..�,�' �luP " .���....
.S i� `J.� � �
"a3C`
y�
1C :��� ����..���
`:1 d
:'z:'i4tN � 53.,.':�i
��41Ni �
i'''+
�. x
�F,
.itdl�11}��q '�.3c
, • � y....�.,
�.. � �.:' ... ., 4;;' �.. A�+'
r,.. a* . ..:;� .��A4 � .�;
''�'�"!__ ��� � ��
� 1
i., ,
�.����� F .� ��.
�#.. 3 I
�
I , , _- 4 ♦
���
� . �� t i'i + � ��.'€ � `
a=�.p�y k
��----� ;.,. . . j
5 ��
�r
r� 0371/M�------.�_.!OS�tryy 8TA F4A1
�'-"_., a r.;
t -: G;E����3�2P���.;� �� ., . "' t'>" �� v��' {
� e.
-'-�---�4L.iACWL'y00�1 � � ��t "�ts*cr. �•
'�`T--�, �YTi�S4_4{.T�EN 9111G�` � '/ s-'y� _ . .... �-^#lKMtOk, 'GW
�-_.�T� �c f' -.... � F
�--�.� 24a_ `���i'Ta � R ��� ,.__^:__� n , n�.
(
T- . .�_ �
��
_ � I ��
i
, ,� � , _ -.. .
.,.. -_._..__ - .. ..: I �� .��._.�
�I
> 1 �.�
�
--_._._' ' -.,
, .,� . � , . }...__..��.,,.,. .. ...
,____. , �. . .
. __"_._ � � � . ... .. --"-" . e ,� .,
. .._-".�-` �
,. , �----�`-- ---�._
;.. _ ' F�OI D(� —�_.._.___,�,� :
� y '�-:__ .�:.. `R Y Rw+n .
_"_' G'-a"-= "._" ou f��rtlef tO ,... :. .
( �nwc - fs ry�wtt 1IM Y� ��� ,~�
4
�LE�GE
r� �x. �
�^�s � qw�f r�Nss tt+m iuH,Vou wlfl ���fi1°��rMc.H tlr aMc r :� �^,2F�h
t ue7�S P�Yfla�O ' '" :
. .- �.-.___,.,__...—Pw y�ftors,�'ta[of S,_-__._... � -
--.-°' ,._..�_. "-- a9�r��t ana�twms snn���� ���
. , ,a� °�P°rtunity to re�lhis�t�YOU qyp�01 thiat�:
` authorize Us ...��.
' -or,� � eonsl��9es tl�.�a°r°�btlepR�#m��c����� �.
� �t ��K.Yaia aF
� �0d�sde on ti�g�t�aWa 9�ehir8 tielOw ta...�
t e
----�� ; All eha °��7t eartl vou�fi�r .
- ��leet to flnaf a�l.
_�---�-°;wEF—� Your Siyro�ura �
-~sua,o..� J ��� �.
'�,�..� w � m
�c�+,ACC � Poii�y PNo�•rome�a,i:eovered v nsurarue �.:,, 2
PsymeM dY Ou�Pe�l i .� �
- PaYmeM trom you�i ^�f09�fed.and We xiti aeeep� � y �
;~- 4ETN00 OF PAV0.IEM MIflt1.S}8[.MII. n�����mWAY WfUIIR�(jmQ I��11�I9 O}
� x a
. " _._. aa�Ey i NEfUNOED �Cf�0/1 7$/�,'� .. �] L�.
� . l+G S _._. .
..._ .. -t �.
... ..p e_ V:SJ. � __- z�
� !
�°... o.vFa � r,iisro� wni..;s � � A
r - _ '
NHCR F-e-�_� - � � . .. �'�.�2 h�t
iMN 100405'-"-'�-L___-. ' .. .
__..__ . ._ -�4::t� �::;C
i �� �
i �W �'_t
s.�b w -
�' � s
� �i
assa y.. . ._... . . ,;'�. A m
. i[�ij.iZ.t'!y 109..-. . ..� . "^+����� � .`aj IA
. rE Z / / ,�f v *nars ss+cn ya�'�•ssa io• ssi_�sa_tioos ..... �,r
- �`i O , �.-i
n e v
��,ro c_ ° a'=l'� *wr -
Luther ioinn9 �'�� � �-. °,� �,
I•��i te2Bearbl a�S�'reet �u �.. "1��v
�651 i �'6! 55 l' eF„�. �.,. .
738-9Q05 � t_,
���.�:I��lil.; E ^�..�1�1�. n� ` . .
�?98?72P7B �r� �� � �`-
DFSCOUER � '"�'
IrRtiru��t�'tl i "`a�"F'°`F` �� �7
,,::tr.�� � � �
SAIE :;IPE� ,�s ?eu,w *� "� =«�r�n
Mar C')`i4 I flV: DQ0003 ��"""w� tv�uru�.� Q'� �cse �x�c .
24� 14 14:q1 �ff� �
...
. ,... AUIH: c"°u,� —_.o�rssrcr�et
02462R �,� �.918�. _ .��:+. ,cav�
m4 Y
:.'i R R 77��.(��.� aao�nE
.__� �;OF.F:�i�"° . euu� oru�an 'ru"t . s . a � .
C';,yl ' . ,..
' ...- �r4WliE110E'Ji�O!E5 -lIN1 � .. .
.�j� .. � aaa, � .
IOiAL - - �i�a 4::- i� , s sn :`
b65.U� ?„,.>.`
... ra�o�ww,._._ -�, � � . ..
- -..'cr;�,':�?Fi. � b
. ._.____ --...
�, ,� i� ..._ -
s�,wrvceacn � � .�� ''n�a J - _______ uT Ea
car��q��![ccM+rI�1�GESUn�EXCE timEaiQMwlst � -r.. - �1'�'` = r
:'i?F(;zy awwi�m w�wcECUw.nv��r`5"`��°�"n��;��Rrns��� '� �,�,'d x ��rs�_�°�oo"''�� �E 'h�ir
� �'�ul'£i . �'v%lNM�'at:'M/J'F1fhiCUm.fl.W�1., '+E U.f:AK45 X V �����M�R'ENO � t � Y�4�..
. . YONMM�£iMVE%f,YG1,5f.C("'1JhIF4r� ._._19�1 -���'�M�S.:,yq h!': WydEiGF➢'Y ��k . � •.
.. V,�CRrFyd!1N qE��_`..0 .
i11
5' ' .' . _.-__._'_.__. ,• �'
�_._.._._�-." - .._.... \ :.. .
� ....... �� �
.._ �Giit f . . �.
�.r
� � � 5
.,�� 4`, � � , <'�Y i � � � •
f t�
� .'� . ' F ti't �I X; . ��• . . , � ' .
H �� s� t
f . � . ti . : . . .
,{:. ��o' ,..��' �`;� � •
.. � �� .;a r :r - '" . . � .r� -� � , . � ,
,� � a•i � _'f-"
. " �y " t � . , . M�'.
-� . �. � . � r' �bP -��-:� . . . .
4 a. . . � �S . . f yy ��� ,!T- ..j� � J . '7.
� � � �z" , ' .�#1 1� ;�' �• :3��� '�. ,i ,k�f.
i� �,.. � �, > r - t, °^` +�`' €
x�.`r��. .. �- �� �� �'r r�'a# r . . _ .
� � ,�'r t�� ��, t }� �'�'`"''e` u .� * .r��
2�..'4 ��*,�,.Y *°� • ' !` .�IY ti 'Y-� �� •` °t .. � . . . �,�,
�' ,5' � y'�s ,.g , . �€�::
� � ,, ( '� �' �+ �r
,� ,+' ,'. � :.,� . �
,
! � Y�` .� L . i. " . . . ' .
�.• � X� S �� :� : � „�• %..
.s ' �^c 4 :�':i . .{ b a .�+f� � ,, <i , f . � . - a��'
r"r -� . � $,. . K :d�� , � � ..
� '�.` ' �. ... �j �� . 3 t�y+ ' . � . .
� .� � � � '��'"�� � - d �• '� - - �' t ��n-°s -_' r '?
c �e
.� f� � ➢Y`�. f : ��{ � a
� '.F .'�� c r, + mj :� ;e��rr
• . ' . a _ -"�*'xca "� �:' w� ..,,c.,-� . .� ,«�.
� . �' - s �,�..r�t �t � ��" *'� � m
_ . . .� ��4 r � °���, ' � , � .. .
'g ' y a M � ;4 ��y�en ° �a g�
, _ � �� " ; ,.•.
' > t ,���i�$`�� " +y� $
9 t�i2 . � y,�♦ �•�{ Ji��a� C�
_�� � . . . . �j �`R ' },��} ` � P`y `k��� �^��. `.. .�
7 .� j �� ,k?. R ,R �, ,:� #��,�`.��j'' 'M V, �F"
� � rj Lf `��' s?� �''��� �"�k' a
.a 3':� � : ' . �,��3. � q: s��'-� .. �: +'� .
��� . .. r b r - �9�3' f# � g � ; '��, ,� ' <
� �+�
k _,�
� � .. � � �'� '��¢)�yv� Y"`*^��"���r ��
ar � �*�°�t�f
� - � - ��� � "� '�:Mlz y.�� �w:��
t �,.
� �,�.. .:. i
�
•
•�
� t.
"rypy
•'Sa
i .
�_
{
���
�1„
f
1
/
�r E
�
i
C
� p" 1t ,r.�,� s ni'J' °�� '��.?g"
,''t t��� i i = yy,�*4����� �'�t, �� "� '� I u '�'tir
. �� .'►.• y ,�x +4��+'�C! � .�� II ��� ��.
t� � "�
� �i��` � F�����t ��.3%`» '�+ �� �y.�� � !
���. � ���,�'�e,x,.. {a g��' �� �,{"' .,, ` s ��1
�
� [.
�.± i a � 7 f ��"°I" .�j�`. �� �'� 1�gb•� , .�'-,�,��`!"`�.�y...m
�t �r � + 9 �
r� ��ll. � ` � 1,. :� .14: 'Y 1��� �nS���..: .. � : , �5��1��w.i���''��-
�
``� d '' '/� "� "S�« +��.sw '� .,,,' ru�'yl�ry. .a ,'�"�"�,a��
� �",�t��'v �1�;� .��y� +q� �s' Fb,.�. ,.+ � :�' tMt .r�i
t y � �� 'T,"y'"���!��'�'a.§tdf'i',�� �' R;�a� � ����'�"��`t��
�'� � �7�� st'��I' it���,�. �.r ` �t". .+r'+E` \� t
+"'t' a 1!!�.. � i�►�` �� �"� 4�i �^�— -. ' ,4 t?�' .� ,re,��A,�� ;i�'
«'.
�
:e
`^�„ �, , � �;���r� ,�y�q.��.�� r,�. �:. � � r�a ti��„� ,
. ,
a "� t ,�,� � ,.t�',t�,�e �� ..��.. , �,w�,,;�, �±�� e �
� , ��� , � �" f�y' � ��� �� . '��,.� �;
.. , . ,�,.• , � 6%_a'�' .�� � ,�,�` =4'4�ta` > .,. �I'4s,'f•4 .
:.�� . ��^ -�,. '�K � y J � ; y +}
� � <� � � ,. i � ,t=.�a� ,�,�:� � .4� ���' � �'4,�,�:
• � u -a16!' �+�` ?�
�k f w
.. � . & � -� I , .s� "��t�^�v' ^..
� > t,� �Y.�� i'� �.r ' ,
�� p.yt a
- .ta ... . .. :`a�'- ..
. . � �. y� �' �...
.. . :. . .. a!�.- � ��ryy � � �y� =.:.ka;:3
.. A
J�:a.°# J ^�s 3.;�..i "'•' � . .... . ��#.,.. .� R�. . _ M1 `.. . '
��"°�.�� �
� b ,�a..,. a� ;' �_ �� �
i a
r M1�5�. � � �' p��w a�' �d ��Y- Q: I li I
r {�f
- . .. � ,r �. a J.'3`;�i,# � �.'�-.
X � a
�• Dtt%
x�.t
stX 1
):,�
� .$ ,..
E
� d ;
. .. .. , � . . e .
� �
�
/ � �
�
�
� i ' - � ..... `_.'RF"�ii-
.. �� � ��� ..
e��
��'
� T�. -
�;
� -�-
. �w � �,`-��-;, . M<.. :_ -._..a
� ,' .. : 4�-"���r =
_
� � ���
"`� ��'
� - , M_ -�.;,,,�
� .
., .
���
.
, „:
or ��
`-�:.. � ,'�r"' �,
`��. .
�, �.
�l �
i�e:,:�,�-.
; _
_ > _. —���;��
, A� i4�-
��' i
� �...� a.:�,.
✓��
'..� � �.. . . � ,�—. -.
:
'� �� y�.` ,�. ��_'_�._.
i�g:: �,� .. _ ——'_' _. . .:�„��+�' "
'
j '
. t,
�: ,
u �.i" i _ .. . ; t . _ ' '
_—
' ' � -. � _... ..z
.� .�_Fr . , . _,... ,
s+s�
: .. . . . �� � � ._�l...�........ . . .
�"� " • - � � .� ..��'t.�- _
. . ... .. . [•,^M��1 .a,,, .� ,...� n _ "
�
a.
,..
t-
� ° ,
a _ __'
�pt
...... ........� � „„..�� .
_� Vw�� w
" --�.._.. �.. _ �
�'� � ..§� �.
�$
�
o��
F
1 I
Y � .
^�
``
V
�;�,
� i. . ���� ` l
% �