Parent RECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota �$ �014
Minnesota State Statute 466.05 states that"...eve erson...who claims dama es rom an munici ali shall cause to be'�%sented��E RK
rY P 8 f Y P �Y... p
governing body of the municipaliry within 180 days afYer 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 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 O'�HER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
� � �N�J �•►rG��
First Name Middle Initial'Vt Last Name
Company or Business Name ��
Are You an Insurance Company? Yes/ 0�1 f Yes, Claim Number?
Street Ad ess ' � I' " ��G��� � �
City al0✓�_ State � Zip Code_��1���
Daytime Phone(/�) �a�- �� Cell Phone(./')��- Evening Telephone( -��L
Date of Accidend Injury or Date Discovered ���' �y Time �-��Uv am L 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. �/-��' �A�L
,� .�r ����� ;�U o r�� � cR,o,�raL / llNI3FL/d SL�— FVLL o ���
'+ Ol.t^s �[l11 TNL flAuErn�wr CDII1i/✓ �-f0/lTt� F O/11 ��� ��4�0 /T�1L y
�� t F2ar✓j f/�'t rFl� i�/;O ,t� �Cf� Xo�E td S 1�/�S G t� ���E�g�-
� �����- �� Rrs � Lvror- t�aFF� � y ��e� �re��r ,yc- ��ry �
SA�Nr a�UL aa��DclSL C�An�nJ�T K�c=A v� r,JiT��! ��rGNiNG �rN�s Sr�E�T.
t�U •' �'�NL' rvcw �r� „a� �,r 1J�stQu� THis -- -
_� ` � anl���►U U'� Ai?�
Please check the box(es)that most closely represent the reason for completing this form: �'��a��`��,�t���p y� � ,
v hicle was dama ed in an accident O My vehicle was damaged during a tow (�
❑ My e g
�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 O 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 atl auplicable 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
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 complete 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 � Unknown (circle)
If yes, what department or agency? , i 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.
Please indicate the amourn you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
�cc �r E
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year �o �-3 Make �-G R D Model T V��S
License Plate Number /��01- 1�+� State�Color ���H/T�
Registered Owner ��- � ����� m• ��'���T
Driver of Vehicle 7�R� � m. �}�2C/��
Area Damaged T��� ��n �����L
City Vehicle: Year ! y� Make � N� Model ���
License Plate Number � M/� State -' Color �" n�l�-
Driver of Vehicle(City Employee's Name) -� �'/�
Area Damaged � N�
In'u Claims- lease com lete this section check box if this section does no
How were injured?
What part(s) of your body ' 'ured?
Have you sought medical treatment? o Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s): --' �
Address ,�' Telephone
Did you miss work esult of your injury? Yes
When did yo ' s work? (provide date(s))
Name our Employer:
A ress Telephone
Check here if you are attaching more pages to this claim form. Number of additional page�. �
�
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 �� ��N-ZDi
Print the Name of the Person who Completed thi�s Form: L7�A�Nr /�• �f�2���
Signature of Person Making the Claim: ��,���� � �'�`'�
Revised February 2011
" iWIN C
win City Wheel Repair �'� Repair Order#0029643
2370 ��� � ' .
Leibel St. Suite 101 �.R,��. ; Date . 3/13/14
White Bear Lake, MN 55110 ��o •
(651) 407-3636 � Page . �
twincitywheel.com
� �w...a�.�,. Center : �
Customer : PARENT, AL Vehicle : 19
Address : 14117 ORCHID License :
Key :
City : ANDOVER, MN 55304- VIN :
HOME : ( 612 ) 282-2385 Ext : Engine : T�•ans :
WORK 1 : ( ) - Ext: Mileage : 1
Op Tech Description
�abor Parts Subtotal
WHE009 NR6 (1) STRAIGHTEN AND R�FZNISH PAINTED WHEEL HYPER i9^
250.00 250.0�
TY WHEEL REPRIR
,e EBEL STREET
,dTiE ERR LA MN 55110
c 1-407-3636
flerchant ID e16103802
Term IU: 19�6
Sale
hASTERCpRD
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flPPrud: Online Batcha; 0a0006 �
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Inv�: 00 0000� Rvpr Code; 03499G
Tota1: 3 250,00
c��coa,�� coPr
THRNK VOU
FOR V I51 T 1 NG e�ecessary pa�s a^r.matenais anc r_racy gram you nndior;���_-�pioyees Labor : $250 00
ats h�ghways or eisevrhere.ai you�.^.:s�r�t�on.for Ihe purpose o!:es;-ng and/or Parts : �0 00
lgee on�he abo�e vehicie io secore�ne amouni ot repars there�e i onoe�stand that
�nce tlue to the unava�labihty ot pan�sr��pmerns beyond their ccntrc� Not Sublet: $0.00
theft or any other cause beyond cu�:onvoi.
- .. . ..,, ,.. �����v��vc ncr�un�is it nnUrv(rt5 pR t2.000 MILES WHICH EVER OCCURS FIRST,UNLESS SPECIFiED Other Fees : $0 00
OTHERWISEvWARRANTY ON WHE.EL REPAIR IS ONE VEAR ON WORKMANSHIP AND MATERIA�S WA,RRANTV DOES NOT COVER
SUBSF�UENT DAMAGE CAUSFD BY CONDITIONS BEYOND OUR CONTROL SUpply CftBfg $O.00
Due to the nature o(wheel repair there are pmes when a wheel is rendered irreparable.We�eservg the righl lo tleem a whee���rreparable We Subtotal : $250.00
will not be iesponsible lor repauing or replac�ng a wheei deemed irreparable Rims not picketl up in 30 tlays will be sold;c de'ray expenses Sales Tax : $0.00
X
Wheel tleemetl�rreparable (NOl(ixable)Cuslomer is advisetl that wheeunm inay be unsa'e��- Pa�d By � TOt81 : $ZSO OO
use m presern con��i�on MSTR CHARG VISA
X____—,. Pay Ref: Pdid : �25�.��
Due : $0 00
Thank you for your business!
'�,�"�� �
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, � CR(�O�KED LAKE TIRE SALES '�
� 2814 134TH AVENUE NW
�^—�� ANDOVER, MINNESOTA 55304
"' 7G3-757-7359
j NAME
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ADDRESS
EMAIL PH. NO. TE� � / �
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SOLD BY CASH C.O.D. CHARGE ON ACCT MOSE RET'D IAYA AY
QTY DESCRIPTION , PRICE AMOUNT
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t' ALL CLAIMS AND RETURNEO(��ADS `�
�,. ;1d;O� �G r�1�°�� MUST BE ACCOMPANIED BY THIS BILL. �
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) LAKE TIRE SALES j
i ti�ar+k v��u� 134TH AVENUE NW
'ER, MINNESOTA 55304
763-757-7359
NAME � n � ��
V6
ADDRESS
EMAIL PH.NO. TE t ^ /
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SOLD BY CASH C.O.D. CHARGE ON ACCT MDSE RET'D LAYA AY
QTY DESCRIPTION PRICE AMOUNT
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TAX j
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" RECEIVED BY TOTAL � : �
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ALL CLAIMS AN RETURNED G�ODS
NO. �i� ���� MUST BE ACCO PANIED BY THIS BILL.
�� � j
1"win �i�y Wheel Repair '� Repair Order#0029643
. ���- �.
Date : 3/13/14
2370 Leibel St. Suite 101 ��,,.
White Bear Lake, MN 55110 � Page : 1
(651) 407-3636 Center : �
twincitywheel.com - - '
Customer: PARENT, AL Vehicle : 19
Address : 14117 ORCHID License : Kev :
City : ANDOVER, MN 55304- VIN :
HOME : ( 612 ) 282-2385 Ext: Engine : T:•ans :
WORK 1 : ( ) - Ext: Miieage : 1
Op Tech Description �abor Parts Subtotal
WHE009 NRG (1) STRAIGHTEN AND REFZNISH PAZNTED WHEEL HYPER 19" 250.0(l 250.00
, ___ _
r ir work to be done alon with the necessar arts and materials and hereby grant you and/or your employees Labor: $250.00
I hereby authorize the epa g Y P
permission lo operate the vehicle herein described on streets,highways or elsewhere,at your discretion,for Ihe purpose of testing and/or Parts : $0.00
!nspeclron An express mechanics lien is hereby acknowledged on the above vehicle to secure the amount o(repairs thereto I undersland that
dealerlowner is not responsible for delay or olher consequence due to the unavailability of parts ship�nents beyond their control.Not Sublet: $0.00
responsible for damage or articles left in car in case of fire,theft or any other cause beyond our control.
WARRANTY ON AUTOMOTNE REPAIRS IS 12 MONTHS OR 12,000 MILES WHICH EVER OCCURS FIRST.UNLESS SPECIFIED Other Fees : $0.00
OTHERWISE.WARRANTY ON WHEEL REPAIR IS ONE YEAR ON WORKMANSHIP AND MATERIALS.WP.RRANTY DOES NOT COVER SU I Char
SUBSEQUENT DAMAGE CAUSED BY CONDITIONS BEYOND OUR CONTROL. pp Y g $O.OG
Due ro the nati�re of wheel repair there are times whe�;a wheel is rendered irreparable.We reserve the right to deem a wheel irreparable.We Subtotal : $250.00
w�ll not be responsibie for repainng or replacing a wheel deemed irreparable.Rims nol picked up in 50 days will be sold to de!ray expenses. Sa�eS TaX : $�.��
X —
Wheel deemed irrepareble (Not fixab!e)Customer is advised that wheel/rim may be unsafe for Pa�d By ' TOtal : $250.00
use in present condiUOn MSTR CHARG V1SA
X - - ---------- — Pay Ref: P81d : �25� ��
Due : $0.00
Thank you for your business!
��� �
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