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Flanagan s _�,_ . �,.,��_ 1 �. c�rr �� ° , ,. 2Nd�f1}IORIZEd NAM€ R� T MATERIAL:ALL PARTS NEW UNLESS SPECIFIE�:U-USED,R-REBUILT,HC-RECONDfRONED � .,. � � � .,. .. �. , � ,. , ' REC IVED(DATE&TIM �S CUSTOMER'S ORDER N0. PROMISED(DATE&TIME� p,M_ , � P.M. P.M. ` Y •MAKE•MODEL "SERIAL#MN MOTOR# � LI�E N0. ODOM R WRfTTEN BY , ' �^ : � i�E �OIL CHANGE ' CJ�L[1SH TRJWS, �FLC1S't#[1�F. '. ��F �PtN.ISH " ' ' C RGE FOR HAZARDOUS OR OTHER WASTE REMOVAL* ; � S , . � � : , . . :,� -�� . , , ti , .�P.., . ; ��_., , , .. . . �� . . _ � . � . � { � � �,v-�� , ,� , - � � , , �� -,,. � � _,. : ��. ._ ��.,� �,�.� � � :.� , .�,. �_ , ;� .� ,_� r. TOTAL PA MELIiOD OF PAY ENT: Dairy Storage fee atter repair wark has been �,pgOR ONLY ��ECK -�CHARGE COmpleted and cus[omer has been notified. No � 1 1� 1 charges shatl accrue or be due and payable for a PARTS �#R'�CAS period of 3 working days from date of notification. , ACCESSORIES LABOR Gua.wwrfeo rr�M(Si GAS,OIL&GREASE � ❑FLAT RATE ❑HOURLY MISC.MERCHANDISE � . ❑BOTH� gUARANTEE EFF'�TIVE UNTIL: Estimated cost$ Estimate Char e Basis for Ch e a SUBLEf REPAIRS �R�TAIN PARTS TIME STORA6E FEE P�EASE READ CAREFULLY,CHECK ONE OF THE STATEMENTS BELOW,AND SIGN; ❑DESTROY PARTS MILEAGE � , � I UNDERSTAND THAT,UNDER STATE LAW,I AM ENTITLED TO A WRITTEN ESTIMATE, ��izEO ar � TA" `' INCLUDING A COMPLETION DATE,IF MY FINAL BILL WILL EXCEED$100,($50 in MD) - �'�M —I REQUESTAWRITTEN ESTIMATE THE FINAL BILL MAY NOT EXCEED THIS i ��-k:: vo�a�ee�cineaey�awrome�et��orauua�ts�e�a�,excxpttlwseforwhich ereisacorecherge,�n�e�s EST�MATE W�THD�T MY W��EN APPR��A�. � y ouu agree Qthenvise by initialing the following:_I do not tlesire the retum of any of the parts ihat are ` replaced dunng the authonzed repairs. — I DO NOT REQUEST A WRITTEN ESTIMATE,AS LONG AS THE REPAIR COSTS DO NOT D(CEED Estimate gdod for 30 tlays.Not responsible fqr d�inage caused by meft,fire or acts�f naUxe.I aNhorize . $ . THE SHOP MAY NOT EXCEED THIS AMOUNT WITHOUT MY WRITTEN OR ORAL APPROVAL �em��°io�me��'mo5�oiiese�9°`�e�o`�,anddelivery a�t my dsk�e�zpf�essemployn��oper�e��m� _ I DO NOT REQUESTAWRITTEN ESTIMATE _ acknowletlgedoniheabove ' sewreiheamouMOfiherepairs cancefrepairspriorbtheir _� comple6on for any reason r-down and reassem6h/f�of will be applied. *Checked lines appty(Preparer must check at least one): ` � SIGNE —This charge represents costs and profits to the motor vehicle repair faciliry for miscellaneous shop supplies or waste disposal. �. 1'� L � GT387� —This amount inciudes a charge of$ ,which is required under law. �� \ _ � ' ��iv�� APR U 12014 NOTICE OF CLAIM FORM to the City of Saint Paul, MinnesotaLERK Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...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,and circumstances thereof,and the amount of compensatian 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 boL'h 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��-��`� Middle Initial �Last Name ��-'�' Company or Business Name Are You an Insurance Company? Yes/D� If Yes,Claim Number? Street Address Z�r� C��V �``� �'� City S� �— State �N Zip Code ��Z Daytime Phone( ) - Cell Phone(�)3��-Ic.zS Evening Telephone(_) - Date of Accidend Injury or Date Discovered 3'Z-�� Time �� a�/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. ►��P�.� ��c-T�l.fc ^��M��'S �Ta G�-— � ?-� �E c Sl\!r L�tJi.� .� —t- a.�.. ,N � �CC� �!_svw�G.� �ap��! � 'Tb ��c�tlC ��-'�''� Please check the box(es)that most closely represent the reason for compledng 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 ❑1VIy vehicie was wrongfuily to�•�d anc.'/c: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�•ou need to include copies of all anulicable 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 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. �'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 andlor 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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-ulease comulete this section Were there witnesses to the incident? Yes � Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes I�'e Unknown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide stre�et address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detailed as possible. Tf necessary,attach a diagram. -1-�nnut�►� t�.J� _ l�{ � �C�..�� p�i�'C � c�' "i�N? IZaLlt�c S'f'.�Tl�i�_ Please indicate the amo nt you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. � gZf3� �T�" �J�a°�� "'��T � ��fl � r'r�x �-� CP.it_ �b �€� A�,�_'i'o n�� Ja2�L 'co AA�� TN� g�i.l�; Vehicle Claims-qlease comnlete this section ❑check box if this section does not avulv Your Vehicle: Year�7- ,��Make -�k�t� Model G��L License Plate Number xMx• Z5� State�Color ��.�c.t�, Registered Owner W�wva� -� �U Driver of Vehicle `� � � Area Damaged �a�sT � City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In�urv Claims nlease comulete this section �check box if this section does not apnly 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 infornzation 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 c�' �- �' 1� Print the Name of the Person who Completed t " rm: ��L-�-U`�l� �L-�1� - Signature of Person Making the Claim: Revised February 2011