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Ward RECEIVE� APR O 1 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�e�t�LERK Minnesota State Statute 466.OS states that"...every person...who claims damages from any municipality...shall cause to be presertted to the governing body of tiie mureicipaliry within 180 days after the alleged loss or injury is discovered a notice statirtg the time,place,artcf circumstances thereof,and the amount of compensation or other re[ief 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 pmvide as muc6 information as necessary to ea�plain your claim,and the amount of compensation being requested. You will receive a written acicnowledgement 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 dces not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL,NIN 55102 First Name Sally Middle Initial�Last Name Ward Company or Business Name Are You an Insurance Company? Yes No If Yes,Claim Number? Street Address 81� Frnnt A��e City 6aint Paul State MN Zip Code 55103 Daytime Phone(.�)�2$- 1844 Cell Phone(651)328- 1844 Evening Telephone(_) - Date of Accident/Injury or Date Discovered March 11,2014 Time B�15 am 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. i was�jyjng o11 Lexinaton, headed South, when i hit a verv larg� nothole in the road It made such a loud noise when , , e , took it to mv repair shop Thev told me I need a new tire because it was ripped and the wheel would �See �tt�cF�ec� ease c ec e x(es)that most closely represent the reason for compleUng 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 vou need to include conies of all apulicable dceuments. For the claims types listed below,please be sure to inclyde the documents indicated or it will delay the handling of your claim. Documents WII.,L NOT be returned and be�ome 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 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 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 c�-r���,,.�-) S� %�1�.�t C�C� � ��,,� need to be replaced due to the severity of the dent. I feel the City is responsible for the damage to my vehicle because of the size and depth of the pothole located in the street. Such a pothole poses a threat to public safety and I believe it is the City's responsibility to monitor the road conditions and correct issues before they become a nuisance to the public. The neglect of such a large pothole on Lexington led to the unnecessary damage to my private property. In the dark, fuil of water,that large pothole was undetectable. The City's neglect of the pothole caused the damage to my vehicle and I expect reimbursement for my expenses. Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please comnlete this section Were there wimesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes No Unknown (circle) If yes,what depaztment 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,attach a diagram. Lexingfon7 be een 3 Iby and Da on in t_.pa��I 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..��n � y�hg cost nf the tire and wheel 1 think that if the nathole had been manaaed when small it would not have caused as much, if anX, damage. Vehicle Claims-nlease comnlete tIL section �check box if this secrion does not annlv Your Vehicle: Year 2012 Make ChevrdPt Model Malibu LT License Plate Number 847HRZ State MN Color Black Registered dwner Jefferv A Ward and Saliy A Ward Driver of Vehicle . ally Ward Area Damaged Tire and Wh��l City Vehicle: Year Make Model Lieense Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv C7aims—please complete this section [�check box if this section dces not anvlv 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 wark as a result of your injury? Yes No When did you miss wark? (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 for►n,you are stating that aZl information you have provided is true and correct to the best of your knowledge. ilnsigned forms will not be processed. Submittiing a false claim can result in prosecution. Date form was completed� �2'�/r�L / � Print the Name of the Person who Completed tlus Form:�,�f� \/�)C�.I�r� Signature of Person Making the Claim: Revised February 2011 Page 1 of 1 All American Auto Service �nvoice _�,.._. .,..a...�i}�.w.�...�--�� 1036 Grand Ave. 28486 '� `� Y ST.PAUL, MN 55105-0000 Estimate Ref#28,815 �� � Shop Phone: (651)298-0766 Date Printed: 03/12/2014 ��:`� � t� 1��'' � Fax: (651)224-9200 Printed Time: 3:18 pm � Email: all.american.auto@comcast.net %+�.� ''�I`� ''! � � �",��`�_ Web Address:www.allamericanautoservice.com HaURef: If you like our service please write review on Google for 5.00 off your next oil change. Time Promised: Ward,Sally 2012 CHEVROLET MALIBU LT L4 2.4L 145CID FI GAS N 0 LE5 813 FrontAve. VIN: 1G1ZC5E08CF151666 SAINT PAUL, MN 55103 License:847HRZ Mileage In: 0 Date written: 03/11/2o1a Home: (651)488-5558 Work: (651)221-1902 un�t#: Mileage Out: 17,690 Written By:John R. Cell: (651)328-1844 �o�� Save Gld Parts: No Job Name Description Technician Qty List Extended New wheel/Tire John R. Part 9598799 Ne�r:whesl. 1.U� 330.49 330.49 Part 920145 Rubber tire pressure sensor valve stem. 1.00 6.91 6.91 Part 066-105 Firestone FR710 P215/55R17 tire. 1.00 128.49 128.49 Misc TIRE DIS. Work Requested-Tire disposal. 1.00 3.50 3.50 Labor 1 Work Requested-Mount and balance tire With transfer 1.00 30.00 30.00 of TPMS sensor to new wheel. Install to vehicle and put spare back to storage. Work Performed-Rotate new tire/wheel to left rear, left rear to left front. Perform tire position relearn. Job Total: 499.39 Parts: $465.89 Payment Date Type Method Amount Labor: $30.00 Sublet: $0.00 Misc: $3.50 Payment Totals: Hazmat: * $2.00 Supplies: * $12.48 Tax Total: $36.47 Invoice Total: $550.34 Like us on Facebook!!