Junker-Axel TIRE PtROS�°� WHEEL EkPERTS
i8�0 �r VIEW DR
HUDSON Wi 54016
715-80�•019�
ierminal ID: 4308175561� Na02
-------- - -----
3i21�14 10:'s2 AM
h1A5TERCARU
pCI;Y 1�: :��xxr».��.�:�xN375
CREGIi SALE
UID; 408045344571 REF �; �466
Bp�CH A: 287 AUTH u: H67331
AMOUNT �4�.46
APPROVED
1NANk YOU FOR
YOUR BUSINESS!
CUSiOMER COPY�
RECEiv�D
�
� APR 0 2 2014
CITY CLERK
� OF CLAIM FORM to the City of.�nt Paul, Minnesota
ne ota 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 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 aclrnowledgement 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 p3ges 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 ��.�.Vl Q-✓�" T�7"U -
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address � "'
City �����►'� State l�� _Zip Code V �
Daytime Phone�)�-�Cell Phone( ) - Evening Telephone( ) -
Date of Accidenb Injury or Date Discovered 3 '�-- Time � � am pm
Please state,in detail,what occurred(happene�,arid wTiy you are submitting a claim.Piease indicate why or how you
feel the City of Saint Paul or its employees are involved and/or resgonsible for your damages.
d.v-' cz �.�- � �.. ,E' Sfi' s i/
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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 accident ❑My vehicle was damaged during a tow
�� vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
—__ - - -- - - -
❑My vehicle was wrongful�y fowed and/or ticketed ❑I was injuredon�ity property
❑ Other type of property damage-please specify
❑ Other type of injury-please specify
In order to process your claim vou need to include copies of all applicable documents.
For the claims types listed below,please be sure to include th�documents indicated.or it will delay the handling of
your claim. Documents WII,L NOT be returned and become the pmperty 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 r.epair 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
Failure to complete and return both pages will result in delay in t6e handling of your claim.
All Claims- lease com lete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: '�n o.,�e. �t�v-S�' - ��1- �(�2--�f�/`1
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 1at�dmark,etc. Please be as detailed as possible. If necessary,attacb a diagram.
�Y'�2..�h�. � �:n �n�- �;� . S`� '�.osvv`��. . Sc)��-h ��' �w.w..�;
Please indicate the amount ou are s king in compensation or what you would like the City to do to resolve this claim
to your satisfaction.����'�
Vehicle Claims- lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year 2_C!l3 Make'��Ck Model
License Plate Number 1.3t� L..�iV State � olar 0�'
Registered Owner
Driver of Vehicle 14
Area Damaged � ir�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In_iurv Claims-alease complete this section ❑check box if this secrion dces not applv
How were you in�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 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
��heck here if you are attaching more pages to this claim form. Number of additional pages 3
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 2� J
Print the Name of the Person who Completed thi orm: � -
Signature of Person Maldng the Cl
Revised February 2011
Tire Pros &Wheel Experts Hudson
1800 Crest View Drive INVOICE
Hudson, WI. 54016 83081
• . Phone - 715-808-0195 Fax-800-395-9661
LOCAL PEOPLE, NATIONAL PRICING!
INVOICE Print Date : 03/21/2014
2013 Buick- Regal GS
JUNKER, MEGAN 2.OL, In-Line4, VIN (V)
1401 NAMAKOGAN RD Lic# : 630LBV Odometer In : 12981
Hudson, WI 54016 Unit# :
Cellular 651-675-6521 Vin# : 2G4GS5EVOD9185166
Cust ID : 27213 Ref# Hat# :
Part Description / Number Qty Sale Extended Labor Description Extended
MOUNTi BALANCE CUSTOMER T1RE MOUNT AND BALANCE CUSTOMERS TIRE
(W/O PUI�CHASE) ON RF
I I.00 24.99 24.99 ROTATE ALL 4 TIRES 12.00
S!i�p Su��li�es 1.4d. I 44 I
[Technicians :WHITCOMB, BRAD]
Org. Estimate SOAO Revisions 50.00 Currert Estimate �0.00 Additicnal Cos. Revised Es,imate Labor: 12.00
Parts: 26.43
Sublet: 0.00
Sub: 38.43
Tax: 2.03
Tota I: 40.46
[Payments- ] Bal Due: $40.46
STORE HOURS: MON-FRI 7am-7pm SAT 7:30am-4pm
l'hanks for choosin;Tire Pros& Wheel Experts! Please remember to re-torque all aluminum wheels within 50-100 miles of them being
removed for service. Unless otherwise noted,warranty on parts and labor is one year or 12,000 miles whichever comes first. For national
warranty inquiries, please call the warranry administrator at 800/351-8432. For national roadside assistance, call 877/430-6487. Free
roadside assistance good for 1 year from last service date!
SIC;NATURE................................................................................................. Date......................................... Time.........................
Wriuen By.FISCHER.ANDY Page 1 Of 1 01.17.07 Copyright Mitchell 1 Invoic1
(2 tmread)-junkermegan-Yahoo Mail https://us-mg5.mail.yahoo.com/neo/latmch?.rand=1m4g1o5fcjnil
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Inbox(2) Fwd: Receipt for your PayPal payment to Flatt T...
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Sent Megan Junker Today at 223 PM
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Trash �
"Folders(1) ,
attorney-accident Megan Axel ;i
divorce
Drafts Beginfonvarded message:
josh deployment
megan From:"serv_ic��ay�aLcom"<serv_ice�payp.aLcom>
—�—`�` —" Notes Date:March 17,2014 at 1228:02 PM CDT
To:meganjunker<meaan iunker3@qmail.com>
parent tips Subject:Receipt for your PayPal payment to Flatt Tire CeMer
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Synced Messag (1)
Hello megan junker,
T.C.
You sent a payment of 567.99 USD to Flatt Tire Center(ftcusedtires�
� Recent
Thanks for using PayPal.To see all the Vansaction details,log in to your PayPal accc
Sponsored tt may take a few moments for this transaction to appear in your account.
�Cw�ea.0(lnrvaesm
Seller Note to seller
NEw year.New you. Flatt Tire Center You haven't included a note.
Nb�e yoa career ftcusedtires(cD�gmail com
fotwa�d.Sfarttoday. �
Shipping address-confirmed Shipping details
Megan junker The seller hasn't provided any
1401 Namekagon St
Apt 306
hudson,WI540167208
United States
Descnption I Unit price
USED MICHELIN PILOT HXMXM4 P'35/SOR18 9N $67.99 USD
235/50/18 235 50 18 235501 S.S0141 8
ttem#191041173227
_. ,,.. ... ._... ._.. . Shipping and h
tr�surance-not
Pa
Payment sent to ftcusedtires rr
Issues with this transaction?
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3/28/2014 2:23 PM