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Henry ��.��i�IED APR 08 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Mi��o�'arLERK Minnesota State Stutute 466.05 states that "...every person...who claims damages from any rnunicipality...s/iall cause to be presented to the governing body of the municipaliry within 180 days after d1e al!eged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and dte amount of compensntiorl or other relief de�nanded." 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. Yoa 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 both 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 N First Name '�� 0 Middle Initial �� Last Name � Company or Business Name IJ� � 7' � �� '�� Are You an Insurance Company? Yes No If Yes,Claim Number? Street Address 2"3� �'�D �'� �� City �1�'�� State �N' Zip Code��3� � Daytime Phone(��-�Cell Phone(��-�� Evening Telephone(��- �� 3 Date of Accidend Injury or Date Discovered D� O�-S ( Time lb:� �m '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 S �nt Paul or its employees are involved an r respon ible for�y our damages� �D SYI��i `�Xt � (}� Gl►'1G� W Iti.�►'� .,L � ►'�,V ��-h-ar1 c. r1 ►- �o�, �- c�-( n .sr• �a�1 .Q I-e ��i� I-ae c�.� o a �a�- l►1 rv'2� . •E r`e �►'� l G�- C�t � �I � ►� �[-8.5 e�_��,�.Q, . 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 �1 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 copies of all applicable 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 and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts �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—please complete this section Were there witnesses to the incident? Yes No Unknown (circle) Z3D ��u� Provide their names,addresses and telephon umbers:_ ��-5�� k-�L, . .��v�_��_ � Were the police or law enforcement called? Yes � Unknown (circle) If yes,what department or agency? n1 I a Case#or report# N�� Where did the accident or injury take place? Provide street address,cross street,intersect�n,name�park or facj,lit��t closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.�,�DVI[,D�, t G�- Dv'1(�l o��tia c�.Pr�_� C.�� -Cod ds. Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claiml� to your satisfaction. 2- 'l 0 ✓ �. G� r fl 1 'S� '(�0✓ G�`eO� v�1h�'el ►rt M r2 ►� r ✓ Cv !�" r�v (� -�L.(1 G�A.��'►� 1.5 reS�1V� Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year�MakeC11��PXfsQ �odel {! �S flW D .�S� License Plate Number i�lo� �� State M� C lor .F3�'�K Registered Owner��>tD A��P�►.�- �--� Driver of Vehicle �l e—R�'Ll� N Area Damaged�� l�.(n� -Pf�� I'I �� 'RtM City Vehicle: Year�Make N�1� Model ��C License Plate Number ►� (pr State!��Color�Il�- Driver of Vehicle (City Em loyee's Name) IJ�t Area Damaged ►��a Injurv 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 �7 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 � � Print the Name of the Person who Completed is o ��'1��' Signature of Person Making the Clai Revised February 2011 fELDMR�NN TMPUf�'TS 4901 AMERICAN BLVD WEST BLOOMINGTON� MN 55437 952-837-6367 Merchant ID: 6?0102215 ierm IU: 2510 $ale hISiRCpRD � XXXXXXXXXXKX4513 Entry Method: S�iped ApArvd; Online Batch�: 000001 44i05i14 15;36,00 Inv�, 0�811649 Rppr Code; 492058 Tot�l: � 1,092,10 Customer Copv THANK YOU! t . r .-� .- -.----- ;�CUS TOMFR #: 14 7 8 21 8 716 4 9 FELDI��INN •I M P O R T S• *INVOICE* 4901 American Bivd. West ANTONIO DARRELL HENRY ' 10999 OAK GROVE CIR UNIT D Bloomington, MN 55437 WOODBURY, MN 5 512 9-8 7 31 PAGE 2 Phone: 952-837-6300 �HOME: 612-991-1183 CONT: 612-991-1183 ° BUS : 612-460-4645 CELL: 612-991-1183 SE�RVICE ADVISOR: 7086 John C Pfeiffer COLOR YEAR ' ' MAKE/MODEL % VIN'' LICENSE ' MILEAGE IN/'OUT ' TAG: !: BLACK 13 MERCEDES E350W4 WDDHF8JBXDA730133 665KUZ 19000 19000 T7043 � DEL.DATE . PROD,DATE WARR. EXP. PROMfSED PO NO. RATE > PAYNlENT? INV, DATE 16FEB13 .I : 16FEB13 D 15 :42 07APR14 0 . 00 CASH 05APR14 'R.o, OPENEp READY OPTIONS: SOLD-STK:M2976 ENG: 3 . 5 Liter 05APR14 05APR14 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL `ALIGN PERF�RM 4 WH�EL ALZ�NMENT ' 9018 CPM 139 . 00 139 . 00 _ _ _ . __ __ _ _ �ARTS: 0 . 00 �P.BOR: �39.00 O'1'HER:c 0 .00 ,TOTAL, LINE E: I< ' 139:00 __ _ _ _,, :. . Tech performed a 4 wheel alignment . ******:***�*******,�********�*******�**��************� F** Tech found a bent LEFT rear wheel . Tire seems fine at this point _ but I ' ll �,o;t for; sure aftez I<; install` it on a new wheel . '; _ MA001 Miscellaneous Maintenance - Repair _ _ _____ _ _ _ _ __ _ _ _ __ _ .. . _ _ _ _ _ _. 9018 C:PM _ , ', 65.<5D 65 ;5� ; _ _ _ _ 1 212-401-31-02-7X10 DISC WHEEL 510 . 00 510 . 00 510 . 00 _ . _ _ _ _ __ . _. _ _ _ _ _ ___ _ ___ _ _ _ _ _ _ _ • PARTS: 510 . 00 LABOR:; ;; 65 .'50 ;:OTHER: 0 . 00 'TOTAL' LINE F: 575:5'0 � Tech replaced the wheel on the LEFT REAR but kept the original tire. . **************************************************** SUBL ZNTERNAL ';.RENTAL ! . ` ' ,:. ... ' IRENT (N/C) < ; _.<.::: • EST: 953 . 71 05APR14 13 : 10 SA: 7086 , . . : _. , ._ _ _ ASK ABOUT FELDMANN IMPORTS ; :; ; .<:, ,, ::: ,. : <':< .. . . *�:OND�fiIONING SERVTCES* , �':; > ; ' >: .: ; ' ' COMPLETE CAR DETATLING < .. ; < '>. . ,_ _ :,.. ,, . __ , .. _ _ :._.. . _,:: _ ., : CLEAR FILM WINDOW TINTING . .. _: _ _:: , __ . __ _ : ' PAINTLESS DENT REPAIR � _ � , DISCLAIMER OF WARRANTIES DESCRIPTfON ' TOTAL'S THE ONLV WARRANTIES APPLVING TO THIS PART(SI ARE THOSE WHICH MAY BE OFFERED BY THE MANUFACTURER.THE SELLING DEALER HEREBV -� EXPRESSLV DISCLAIMS ALL WARRANTIES,EITHER EXPRESS OR IMPLIED,INCLUDING ANV IMPLIED WARAANTIES OF MERCHAN7ABILITV OF FI7NESS FOR LABOR AMOUNT 2 3 6 . 7 S ' 'A PARTICULAR.PURPOSE,AND NEITHEF ASSUMES NOR AUTHOFiIZES ANY OTHER PERSON TO ASSUME FOR IT ANV LIABILITY IN CONNECTION WITH THE SALE OF THIS PARTISI AND/OR SERVICE.BUYER SHALL NOT BE ENTITLED TO RECOVER FROM THE SELLING DEALER ANV CONSEQUENTIAL DAMAGES, PQRTS AMOUNT '�8� `�5 � DAMAGES TO PROPERTY,DAMAGES FOR LOSS OF USE,LOSS OF TIME,LOSS OF PROFIT,OR INCOME OR ANY OTHER INCIDEN7AL DAMAGES. Any warranties on the products sold he�eby are those of the manufacturer.As between this retail seller and buyer,the product is to be sold"AS IS'and the GA$,��, LUBE U . O O entire risk as to the quality and peAormance of the product is with the buyer.The seller ezpressly disclaims all Narranties,either exDress or implied.including SUBLET AMOUNT O . O Q any implied warranty of inerchantability or fitness tor 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 seller in no way affecfs the items of the manufacturer's warranty.The buyer MISC. CHARGES 12 . 5 0 .acknowledges being so intormed prior to sale. TOTAL CHARGES 10 3 5 . 5 0 X LESS INSURANCE � . �� LAST INVOICE#/DATE: CLAIMS FOR WORK PERFORMED ALL PARTS NEW ORIGINAL SALES TAX 5 7 .2 0 MUST BE MADE WITHIN 90 DAYS OR SHOP'SALES 4,000 MILES WHICHEVER COMES EQUIPMENT UNLESS p�EASE PAY FIRST FROM DATE OF WORK. OTHERWISE SPECIFIED THIS AMOUNT 1 O g2 . 7 O THANK-YOU Copy�iph�2000ADP.lnc.SERVICEINVOICETVPE2-Si2C CUSTOMER COPY � � CUSTOM�R #: 14 7 8 21 8 716 4 9 FEL.D1��11NN •IMPORTS• *INVOICE* 4901 American Blvd. West ANTONIO DARRELL HENRY eloomington, MN 55437 � 10999 OAK GROVE CIR UNIT D WOODBURY, MN 5 512 9-8 7 31 PAGE 1 Phone: 952-837-6300 HOME: 612-991-1183 CONT: 612-991-1183 BUS : 612-460-4645 CELL: 612-991-1183 SERVICE ADVISOR: 7086 John C Pfeiffer GOLOR YEP.R MAKElMODEL ''' VW ' L1C�NSE ' MILEAGE IN/OUT TAG> � BLACK 13 MERCEDES E350W4 WDDHF8JBXDA730133 665KUZ 19000 19000 T7043 ' DEL:DATE ' PRaD;'DATE :WARR.'EXP. PROMfSEO'` PO N0. !I RATE PRYMENT ;i IIVV. �AT£ _ �16FEB13 I 16FEB13 D 15 :42 07APR14 0 . 00 CASH 05APR14 R.o. OPENED :: READY : OPTIONS: SOLD-STK:M2976 ENG: 3 . 5_Liter 05APR14 05APR14 ZINE OPCODE TECH TYPE HOURS LIST NET TOTAL •A TOW IN ' _ 00 CUST STATES 9Q18 CPM 0 ;`00 ' 0',0� PARTS: 0 . 00 LABOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE A: 0 . 00 • ***�***�**�*�*v�****�***�**��**��;*�*******,�******�*** _ , ` B COMPLIMENTARY MULTI POINT INSPECTION , MPI COMPLIMEN`PARY MULTI POINT INSPECTION • 9018 CPM 0 . 00 0 . 00 PARTS: 0 .;00 LABOR>; 0 . 00 OTHER; 0 .00 TOTAL LINE B: 0 . 00 Good shape at this time. �***�******�*****************************�**,�******* ..'C CUSTOMER STATES: HIT A POT HOLE, FRONT TIRE IS POPPED AND BACK RIM IS CRACKE:D, PL,EASE' ADVISE .. ... 00 CUST STATES 90';18 CPM ' , 0`: 00 ' 0 . 00 ' PARTS : 0 . 00 LABOR: 0 . 00 OTHER 0 . 00 TOTAL LINE C: 0 . 00 Tire is not repairable. >: .. ' ' **************************************************** '•D** 'MOUNT AND BALANCE 1 TIR�, ROAD TEST,FOR QUALITY.' Tire is not _ repairable. Parts - 245/40/18 contiprocintact , '!MB1 'MOUNT AND' BALANCE 1, •'�.'�RE,., �4AD .�':�S'� k'OR '-. _ . QUALITY ; 5Q18 CPO ' 32:25 ' 32j!25 '' , ', __ _ _ 1 . 75 1 . 75 l Q-8-40-0765 CONTINENTAL 245/4OR18 SKU, � 0350443, 276 .25 276 . 25 276 .25 HW2PN1H606;.14 ' ' ' ' . � PARTS : 276 .25 LABOR: 32 .25 OTHER: 1 . 75 TOTAL LINE D: 310 25 Tech mounted;!and balanced. !1 new tire on the LEFT >FRONT , ', _ **************************************************** E** PERFORM 4 'WHEEL AI��GNMENT '. , ' ' > _ , CAUSE: INSPECT TIRES, SUSPENSION, AND STEERING COMPONENTS,ADVISE ON CONDITION, PERFORM 4 WHEEL ALIGNMENT 'PER MERCEDES SPECIFICATIONS ROAD TEST DISCLAIMER OF WARRANTIES bESCRIPTION TOTALS • THE ONLV WARRANTIES P.PPLVING TO THIS PART(SI ARE THOSE WHICH MAY BE OFFERED BV THE MANUFACTURER.THE SELLING DEALER HEREBY - EXPRESSLY DISCLAIMS ALL WARRANTIES,EITHER EXPRESS OR IMPLIED,INCLUDING ANY IMPLIED WARRANTIES OF MERCHAN7ABILITY OF FITNESS FOR LABOR AMOUNT . A PARTICULAR PUFPOSE,AND NEITHER ASSUMES NOR AUTHORRES ANV OTHER PERSON TO ASSUME FOR IT ANY LIABILITV IN CONNECTION WITH THE - -SALE OF THIS PARTISI AND/OR SERVICE.BUVER SHALL NOT BE ENTITLED TO RECOVER FROM THE SELLING DEALER ANV CONSEDUENTIAL DAMAGES, PARTS AMOUNT ' - DAMAGES TO PROPERN,DAMAGES fOR LOSS OF USE,LOSS OF TIME,LOSS OF PROf1T,OR INCOME OR ANV OTHER INCIDEN7AL DAMAGES. GAS,OIL,LUBE � Any warranties on the products sold hereby are those of the manufacturer.As between this retail seller and buyer,the product is to be sold'AS IS"and the SUBLET AMOUNT entire risk as to the quality and pertormance of the product is with the buyer.The seller exDressly disclaims all warranties,either express or imD�ied,including ,any implied warran[y of inerchantability 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 seller in no way affects the items of the manufacturers warranty.The buVer MISC. CHARGES acknowledges being so infortned pno�to sale. TOTALCHARGES X LESSINSURANCE LAST INVOICE #/DATE: CLAIMS FOR WORK PERFORMED ALL PARTS NEW ORIGINAL SALES TAX SHOP SALES MUST BE MADE WITHIN 90 DAYS OR EQUIPMENT UNLESS pLEASE PAY 4,000 MILES WHICHEVER COMES OTHERWISE SPECIFIED FIRST FROM DATE OF WORK. THIS AMOUNT THANK-YOU /� /� /�/� Coovrian�2000ADP.Inc.SERVICEINV0ILETVPE2-512C I.TT�Tl1MFR \.\1PY � � M�rcedes Benz 4901 American Blvd W � � � - � - Bloomington, MN 55437 Repair Order# Customer Information Vehicle Information Name Phone Number Today's Date Year Make Model Mileage 871649 Antonio Darrell Henry (612)991-1183 04/05/2014 2013 MB E350W4 19000 Email address VIN SWte Inspection Due henryantonio C�live.com WDDHFBJBXDA730133 Legend I�Passed Inspection ❑May Require Attention ,�Requires Attention NI=Not Inspected NA=Not Applicable *=See Comments Check the Following Systems or Components Li hts/Horn/Blades Batter Lights:Interior&Exterior,Turn Signals,Hazard,Brake � ❑ � Battery Condition � ❑ � Horn Operation � ❑ � Battery Cables and Connections � ❑ , Front Wiper Blades (�f ❑ � Factory Spec Cold Cranking Amps amps Rear Wiper Blades �( ❑ � Actual Cold Cranking Amps amps � ❑ , Fluids Fill? Ins ect for Visual Leaks Window Washer Reservoir �( ❑ � Fuel S stem and Gas Ca Seatin ❑ � Coolant Reservoir �i ❑ � Engine,Transmission,Transfer Case,and Brakes � ❑ , Coolant Protection(Good to °F) �i ❑ � En ine Coolin S stem � ❑ � Engine Oil � ❑ � Shocks and Struts—leaks and operation � ❑ , Power Steering Reservoir e( ❑ - Ins ect for Visual Condition Battery(if not maintenance free) � ❑ � Belts:(Engine,A/C,Accessor ,and other) ❑ � Transmission Fluid � ❑ , Air Conditioning Temperature °F � ❑ O Brake Fluid Reservoir � ❑ � Exhaust S stem Com onents � ❑ � Filters Hoses:(Radiator,Power Steering,Heater,and A/C) � ❑ e Engine Air Filter ❑ � Steerin Components and Linkage � ❑ � Fuel Filter ❑ � Driveshaft,Drive Axle Boots,and U-joints � ❑ ,, Cabin Air Filter ❑ � Tire/Brake Wear Left Front � � Rightfront � ❑ ,� TireTread Depth 8_/32" � ❑ ,� TireTread Depth �32" Tire Wear Tire Wear Tire Pressure @_ Set to 35 Tire Pressure @_ Set to 35 �j ❑ � Brake Lining 9 mm �32" � O � � ❑ � Brake Lining 9 mm _J32" Left Rear � � Right Rear � ❑ � TireTread Depth �32" �� ❑ � TireTread Depth �32" Tire Wear Tire Wear Tire Pressure @_ Set to 35 � Tire Pressure @_ Set to 35 ❑ + Brake Lining 9 mm _J32" ❑ � Brake Lining 9 mm _/32" � � Tire Wear Indicates Ali nment Needed � ❑ ♦ Tire Rotation Needed � ❑ � Wheel Balance Needed � ❑ � Comments• John C Pfeiffer Tony K Ivanov Service Advisor Technicfan Customer Signature ADP,Inc.Dealar Servicee Group/1950 Hassell Road/Hoffman Eslatas,IL 80189-6308/adpdealerservices.com/888.424.6342 J� � m2009ADP,Inc-Dealer Services Group IADP is a registered trademark ofADP,Inc. fELDMR�NN TMPOff'TS 4901 AMERICAN BLVD WESi BLOOMINGTON. MN 55437 � 952-837-6367 Merchant ID: 679102215 i-rrm IU: 2510 Sale MSiRCRRD •. XXXXXXXXXXXX4513 Entr� Method; S�iped ppprvd; Online Batch�: 000001 . 04i05i14 15:3fi:00 Inv�; 04871649 Rppr Code; 092056 Total; � 1�092,t0 Customer CopY THANK YOU! p t' � r� . �CUS TOMFR #: 14 7 8 21 8 716 4 9 FELDI��INN . ,, � •I M P O R T S• *INVOICE* ANTONIO DARRELL HENRY 4901 American Blvd. West : 10999 OAK GROVE CIR UNIT D Bloomington, MN 55437 WOODBURY, MN 5 512 9-8 7 31 PAGE 2 Phone: 952-837-6300 �HOME: 612-991-1183 CONT: 612-991-1183 . . BUS: 612 460 4645 CELL: 612 991 1183 SERVICE ADVISOR: �os6 John C Pfeiffer ., �OLOR ;YEAR s;; 1VIAKE/MQDEL ' ':;:E.IGENS,E ';:NfIi.EAG.�I�t f OiUT . ° VW '::: ;. TA� BLACK 13 MERCEDES E350W4 WDDHF8JBXDA730133 665KUZ 19000 19000 T7043 REL; DATE ;PROD, DATE V!(ARR EXP PRQ:MfSED :; Pa:::NO ;RATE PAYMENT _; !INV DAT£ >:. >: • 16FEB13 .I ' ' 16FEB13 D 15 :42 07APR14 0 . 00 CASH 05APR14 R.o oPEN.�p ;R�ADY;; ;; oPT�oNS: SOLD-STK:M2976 ENG: 3 .5 Liter 05APR14 05APR14 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL ALTGN:;PERF;ORM 4', WH�ET� .AL�GNMENT . ;; ' ` 9018 CPM ; ; 139 00 139 00 �ARTS ?. . ; 0 : 0:0 LABOR ::: OTZ�ER 0 00: , ` ::Z39 ,Q;O 1:39 0'.Q > TpTAL ;LZNE;<� . . :.: . , Tech performed a 4 wheel alignment. -> ,;; < �*;*�*�*:**��;*�***:*�******�*�*�*:***�;�***�:**�;*��a�**<***�:.: F** Tech found a bent LEFT rear wheel Tire seems fine at this point ;:; _ : but z'�;l r�ot: �qr'; sure: after � ;i�stal7, xt o�`;a new w�eel MA001 Miscellaneous Maintenance Repair :". > 907..8 C�M _: ' 6 5 5 0 ;6� 5;D 1 212 401 31 02 7X10 DISC WHEEL 510 00 510 00 510 00 PARTS' ;: . 5:1 D 0 0 �ABOR ' `.65 5 0 OT.HER: >' 0 O O;i: T.O`�AI� :LIN�:::F 5 7 5 . 5 0: :, Tech replaced the wheel on the LEFT REAR but kept the original ,. , , ; < < _ ,. tire :>. _ . , , , _:; . ... ,_. ; ,:; .::: _ ;,: , .: **************�*********:*********�****************** , SUBL. ZNTER,I�TAL RENTAI�;; ;!; ; ;! ' . ; :.<.... �' , I RENT .. , ; ;< " ,; _:: , . , ,. : ,,< ,, i..:> ,, ; ; ; ,.. ;:..; » > _ ..,.> . ;,< _ ,;. ; . • EST: 953 . 71 05APR14 13 : 10 SA: 7086 _ ASK ABOUT FELDMANN IMPORTS ;: . > .. ;:<; '; '. : . .:;*�ONII�'I'�pNING. :;SER'VYCES*'! '' :,: . . , .. _ ;' � , . . '>COMPL;ETE :CAR D�TATLING.; ;. _ __ _._ : ,: ; , , : CLEAR FILM '> ;: <: ;:: ;. <: WINDOW TIN.TING : , _ ,_: � PAINTLESS DENT REPAIR DISCLAIMER OF WARRANTIES " - DESCRI�TION..; TOTALS:::;:; THE ONLY WARRAN7IES APPLVING TO THIS PARTISI ARE THOSE WHICH MAV BE OFFERED BY THE MANUFACTUFER.THE SELLING DEALER HEREBY �' �� EXPRESSLV DISCLAIMS ALL WAFRANTIES,EITHER EXPRESS OR IMPLIED,INCLUDING ANV IMPLIED WARRANTIES OF MERCHANTABILITV OF FITNESS FOR LABOR AMOUNT 'A PARTICULAH.PURPOSE,AND NEITHER ASSUMES NOR AUTHORI2ES ANY OTHER PERSON TO ASSUME FOR IT ANY LIABILITV IN CONNECTION WITH THE 2 3 6 . 7 5 SALE OF THIS PARTISI AND/OR SERVICE.BUYER SHALL NOT BE ENTITLED TO RECOVER FROM THE SELLING�EALER ANV CONSEQUENTIAL DAMAGES, Pp,RTS AMOUNT �7 DAMAGES TO PROPERTY,DAMAGES FOR LOSS OF USE,LOSS OF TIME,LOSS OF PROFIT,OR INCOME OR ANY OThIER INCIDENTAL DAMAGES. /H 6 .�S Any warranties on the products sold hereby are those of the manufacturer.As between this retail seller and huyer,th.e product is to be sold"AS IS'and the GA$,Q��, LUBE � . 0 O entire risk as to the quality and per}ormance ot the product is with th@ buyer.The seller expressly disclaims all warranties,either express or implied,including SUBLET AMOUNT any implied warranty oT merchantability or fitness for a particular purpose,and the seller neither assumes nor auihorizes any o[her person to assuma for it any Q . Q O liability in connec[ion with the sale of said products.This di5claimer by this seiler in no way affects the items of the manufacturer's warranty.The buyer MISC.CHARGES .acknowledges being so informed prior to sale. �� . c O J X TOTAL CHARGES 10 3 5 . 5 0 LESS INSURANCE O . O O LAST INVOICE#/DATE: CLAIMS FOR WORK PERFORMED qLL PARTS NEW ORIGINAL SALES TAX 5 7 . 2 0 SHOP SALES MUST BE MADE WITHIN 90 DAYS OR EQUIPMENT UNLESS 4,000 MILES WHICHEVER COMES OTHERWISE SPECIFIEb P�EASE PAY FIRST FROM DATE OF WORK. THIS AMOUNT 1Qg2 7O THANK-YOU opY��9h12000A0P,lnc.SEflVICEINV0ICETYPEI-S11C CUSTOMER COPY • ` /_'1- .CUSTOM�R #: 147821 871649 FELDl��1NN • . •IMPORTS• *INVOICE* 4901 American Blvd. West ';ANTONIO DARRELL HENRY Bloomington, MN 55437 • 10999 OAK GROVE CIR UNIT D �'.WOODBURY, MN 5 512 9-8 731 PAGE 1 Phone: 952-837-6300 �� HOME: 612-991-1183 CONT: 612-991-1183 BUS: 612-460-4645 CELL: 612-991-1183 SERVICE ADVISOR: 7086 John C Pfeiffer GOLOR > YEAR >; MAKE/M.:ODEL . UIN:;:; ;:>L10EN5;E i NEII:EAGE IN l,OUT ;; TAG: :::: _ _ _ _ _........_ , . _._ _ ..... : BLACK 13 MERCEDES E350W4 WDDHF8JBXDA730133 665KUZ 19000 19000 T7043 k ': DEL`!DATE >: PROD, DATE ;1NARR:EXP F;RQMfSED:;: PQ:fV0 ;RRT� s P,RI'NEENT;:; ; ;;(NV RAT�,. : . ,.. _.... ......_ ..: . ..,......_ _....... • �16FEB13 I 16FEB13 D 15:42 07APR14 0 . 00 CASH 05APR14 R:O .OPENED <; REAL71' OPTIONS: SOLD-STK:M2976 ENG:3 . 5 Liter ' 05APR14 05APR14 ZINE OPCODE TECH TYPE HOURS LIST NET TOTAL 'A TO.W;i IN . ... _::. __ _ .. _... _ .... ....... . _ _ _ 00 CUST STATES , :•:::. .. ... '> ;: 9.0:1.8 . C:PM i ;:``. ;' . ; 0 :0 0. 0 <Q 0 �PARTS: 0 . 00 LABOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE A: 0 . 00 . _ . ..: �.;**�x**>*�**_�:*�*�;**��v�:��*.�:**�**;**�*<��**��**��*��;*�**� ;: . ;> ; . ;;. ;: ,_ ,. . : : ` B COMPLIMENTARY MULTI POINT INSPECTION , ;::MPI CQMPL'IMEN`�'ARY MUL'Z'zi;; POIN'I' zNSPECTrION <: _ _ _ _ 9018 CPM 0 . 00 0 . 00 ..P,ARTS'i _.. 0 :00 , �ABOR°; D Q;O. OTHER: 0. 0<0 TO'Z`i�L+;>LINE; B Q .;00 Good shape at this time . �:**��w;*�**�:�*��.**�*�;**�*�***�,**��:v��***�*w��:****;****;�;: • .:. . .:. ;:.. , . : ..:.. , ,: _ _ : ,:'C CUSTOMER STATES . HIT A POT HOLE, FRONT TIRE IS POPPED AND BACK RIM IS ..: „ <:: < CRI�CKE:D, . P�EASE;>:ADVI�E ;::: ' ' _ 00 CUST STATES , : <. 9Q18 .. C',PM < . .. . ..' � ; , : ' ..... ...1 ' ' 0 ;>0 0. 0 :'0 0 . .: . _:. . , ....� PARTS : 0. 00 LABOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE C: 0 . 00 _ ;- �:;,Tire is ;ri:ot. r..epair:able;: - :.:. < ; **************************************************** ,: , ;.D**., MOUNT::AND BALANCE .1,;TIRE>; RQAD TE;ST..:FQR QUALITY;. Tire is;;n�t ::: . re airable. Parts ,245%40/18 contiprocintact P �. MB1 .MorrnrT` �rrD <$A�x�c� i<: �zR�, �o� ,�r.�s� ;�oR _. _ , F�� , : . . _ QUALITY ; . ;, ,. . ; , - � �' , ,, . •<:> , s: 901;8 C:PO... > . . < 32 .25. . : 32 .25 , , 1 . 75 1 . 75 < 1:::Q .8 .;40. 07;65 CONTINENTAL, 245/40R18 SKU; ` ' 0350443, 276 .25 276 .25 276 .25 _ HW2PN1H60.6I4 _ � PARTS: 276 .25 LABOR: 32 .25 OTHER: 1 . 75 TOTAL LINE D: 310 .25 ;Tech;mota.n�ed and b:a�anced 1; n�w :tire.: on..the T�EFT F;RONT _ _ ******�********************�*********�************** . .. _ . , E:** .PERFORI`� 4 :WHE�Li; ,AU�CNMEN'�' ....... .' CAUSE: INSPECT TIRES, SUSPENSION, AND STEERING COMPONENTS,ADVISE ON , GONDITION, ;PER�ORM;�k; WHE.EL AL�IGNMENT PER MERCEDES SPECIFICATIONS ROAD TEST . DISCIAIMER OF WARRANTIES DESCRIPTION `. TOTAL:S::.,, ; . _...,:..._.. _....._. >: ._,...'..... ............. :. �• THE ONLV WARRANTIES APPLYING TO THIS PAPTIS)ARE THOSE WHICH MAY BE OFFERED BV THE MANUFACTURER.THE SELLING DEALER HEPEBY �� EXPRESSLY DISCLAIMS ALL WARRANTIES,EI7HEF EXPRESS OR IMPLIED,INCLUDING ANY IMPLIED WAFRANTIES OF MERCHANTABILITY OF FITNESS FOR LABOR AMOUNT . A PARTICULAR PURPOSE,AND NEITHER ASSUMES NOR AUTHORIZES ANY OTHER PERSON TO ASSUME FOR IT ANY LIABILITY IN CONNECTION WITH THE � �SALE OF THIS PARTISI AND/OR SERVICE.BUYEF SHAIL NOT BE ENTITLED TO RECOVER FROM THE SELLING DEALER ANY CONSEQUENTIAL DAMAGES, pARTS AMOUNT ' � DAMAGES TO PROPERTV,DAMAGES FOR LOSS Of USE,LOSS OF TIME,LOSS OF PROFIT,OR INCOME OR ANY OTHER INCI�ENTAL DAMAGES. �� Any warranties on[he products sold hereby are those of the manufacturer.As between this retail seller and buyer,the product is to be sold"AS IS"and the GAS'��,LUBE entire risk as to the quality and performance of the product is with the buyer.The seller ezpressly disclaims all warranties,eithei express or implied,including SUBLET AMOUNT ,any implied warraniy of inerchantability 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 product5.This disclaimer hy this seller in no way affects the items of the manufacturer's warranty.The buyer MISC. CHARGES acknowledges being so informed prio�to sale. ; ' TOTALCHARGES x LESSINSURANCE ',LAST INVOICE #/DATE: CLAIMS FOR WORK PERFORMED ALL PARTS NEW ORIGINAI SALES TAX SHOP SALES MUST BE MADE WITHIN 90 DAYS OR EQUIPMENT UNLESS 4,000 MILES WHICHEVER COMES OTHERWISE SPECIFIED PLEASE PAY FIRST FROM DATE OF WORK. THIS AMOUNT ' " >: � THANK-YOU �Coovrluht2000ADP,lnc.SEPVILEINVOICETYPE7-512C l.TT�TnMri.R �nDV I�!ercedes Benz = � 4901 American Blvd W f��`� �� , � � � _ � _ Bloomington, MN 55437 �� Repair Order# Customer Information Vehicle Information 871649 Neme Phone Number Today's Date Year Make Model Mileage Antonio Darrell Henry (612)991-1183 04/05/2014 2013 MB E350W4 19000 Email address VIN State Inspection Due henryantonio C�live.com WDDHFSJBXDA730133 Legend �Passed Inspection ❑May Require Attention �Requires Attention NI�Not Inspected NA=Not Applicable *=See Comments Check the Following Systems or Components Li hts/Horn/Blades Batter Lights:Interior&Exterior,Turn 5ignals,Hazard,Brake � ❑ V Battery Condition � � � Horn Operation � ❑ � Battery Cables and Connections � � � Front Wiper Blades � ❑ � Factory Spec Cold Cranking Amps amps Rear Wiper Blades Pf ❑ ,� Actual Cold Cranking Amps amps �f ❑ � Fluids Fill? Inspect for Visual Leaks Window Washer Reservoir � ❑ � Fuel S stem and Gas Ca Seatin � � Coolant Reservoir � ❑ � Engine,Transmission,Transfer Case,and Brakes � ❑ � Coolant Protection(Good to °F) � ❑ � Engine Coolin System � � � Engine Oil � ❑ � 5hocks and Struts–leaks and operation � ❑ � Power Steering Reservolr �( ❑ � Ins ect for Visual Condition Battery(if not maintenance free) � ❑ � Belts:(Engine,A/C,Accessory,and other) ❑ � TransmissionFluid � ❑ � AirConditioningTemperature °F �i ❑ � Brake Fluid Reservoir � ❑ � Exhaust S stem Components � ❑ � Filters Hoses:(Radiator,Power Steering,Heater,and A/C) � ❑ � Engine Air Filter ❑ � Steering Components and Linkage � ❑ � Fuel Filter ❑ � Driveshaft,Drive Axle Boots,and U-joints � ❑ � CabinAirFilter � � Tire/Brake Wear Left Front �� Right Front � ❑ ,� TireTread Depth $_l32" —'—'— � ❑ � TireTread Depth �32� Tire Wear Tire Pressure @_ Set to 35 � Tire Wear � ❑ � Brake Lining 9 mm _/3�" � �� Tire Pressure @_ Set to 35 t� ❑ � Brake Lining 9 mm _�32" Left Rear � � Right Rear � � ,� TireTread Depth �32" Tire Wear ' � , � ❑ a� TireTread Depth �32u Tire Wear Tire Pressure @_ Set to 35 Tire Pressure @_ Set to 35 ❑ � Brake Lining 9 mm _J32" � � ❑ ,� Brake Lining 9 mm _J32" Tire Wear Indicates Ali nment Needed � � ,1 Tire Rotation Needed � ❑ ,,1 Wheel Balance Needed � ❑ ,� Comments• John C Pfeiffer Tony K Ivanov Service Advisor Techniclan Customer Signature ADP,Inc.Dealer Servicea Group/1950 Hassell Road/Hoffman Estates,IL 60169-6308/adpdeaiarservicas.com/888.424.6342 J � m2009 ADP,Inc-Dealer Services Group/ADP is a registered tredemark of ADP,Inc. • � � � Henry, Antonio From: Antonio Henry <henryantonio@live.com> Sent: Monday,April 07, 2014 11:35 AM To: Henry, Antonio Subject: Fwd: f Sent from my iPhone Begin forwarded message: From: "Ekdahl, Chris" <Chris.Ekdahl(c�bestbu .��com> Date: Apri15, 2014 at 12:54:00 PM CDT To: "henrvantonio(a�live.com" <henryantonio(a�live.com> � � �. :. 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