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Wilson RECEIVED APR 0 7 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota ��rY C�.�� Minnesota Str�te Siattue 466.05 stntes that"...every•pe�•son...x�/rr�clai»is damtiRes f'ran ari��rrtunicipality...shall eause to be prese�ate to t e gc�ven�iTZg body of�Ihe municipalih-wilhi�a 180 detys u/'ter the alle,qed loss or anjuiy is discouered a nol'ice stutifak�he time,pluce,and c�drei�mstances thereqf,��n�!tlte<�mouru of co»:�erisatiori or�ther 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 eYplain 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 campleted. 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 ��(I Middle Initia] !-- Last Name W� �.�On Company or Business�Iame Are You an Insurance Company? Yes No Yes,Claim Number? 'c"' Street Adciress �� t�7 S Gt a n n o� �/1�qc,� �/�/�S"E'— City �.osernoUn�l- State M�/ifleSa`E`q, Zip Code 5��6 D llaytime Phone(D �)�6-�a� Cell Phone(6 ��)�dQ�Evening Telephone( ) - Date of Accident!Injury or Date Discovered, ! � � f �� Time � �� am/ m� P]ease 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 em loyees are involved and/or responsible for your damages.�_�d-� �� wt �n � vKoms i✓� s�h au • Wh n � an `fron-r o W e c �c ✓►t► ll �d . t ' � t,s I u S o ncte e i� h na�c I��ns�- � atu0t d a I� �l w�cs -�-v . �ef c. u.b Vi wo � ,�►r� �-he �#- Ytivte t tn�� -}h�erEduc -E-d t�-- �a�rlr�i � te +he � r� Please check the box(es)that most closely represent the reason for completing this form: ❑�✓Iy 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 O [ was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify ` to include cv- �.,11,� .�.�� h a.o�. ''t'�t�l�� I o�-d 1 � n da rn�y�s a f e �Tl��' For ude the doc l yow � �5� • �d � '�-D PO�"�/1b�L.'come the� � �1Ur1'.�" rj�lr✓1 �S 1�1�t� � cop; p, V a J C �v n� timates for k1�.� d► d�n� t^ �(y5 br'dn� 11tW Ca l' �LSS he repairs � �` � /f��U.t� � � MP ' �an �� rn�'� �-i �1 , issued and� 'TU ►u � r - -k`� ;timates if tl f _ ` ' ��n� On rt�u.S Y�. • . ��oo � � � L� ��_f amaged iter W!� �� 1 f� (� �rch�td �,r' dQ/►�q�1�S �C�jdt(�• snt and supp �U6T� f $ rt'arn d� � �i � and return � , `Th�n1-� . Failure to complete and return both pages will result in delay in the handling of your claim. All Claims– lease com lete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names,adciresses and telepho numbers: Were the police or law enf'orcement 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,ndme of pa• ��cility closest landmark, etc. Please be as detailed as ossible. 1f necessary, attach a dia ram. C�ti3'� d �a �-s au �. e-�4-c n o d l�, l► c Please indicate the amountY,ou are tieek' g in campensation or what you w ld like the City to do to resolve this claim to your satisfaction. �W I'�c+� rl'l /1 O� C OU e�' G�GI/J'tU t feo a��rs due +o S t-� oo-� Ylble � D a m cs e -ft� Qn e rr m. �To-�u� amo u n-� Se�e,f�c.a n� � �� d Vehicle Claims– lease com lete this sec on ❑ check box if this section does not a 1 Your Vehicle: Year�b 1� Make 4�Odc�_ Model ar License Plate Number —� State��Color L�t ader 0 c'anAe Registered Owner � L W' Driver of Vehicle� t�- q_�IN:L�n Area Damaged �hG� fl►rR� a 1 l i�tn�' City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injurv Claims–please complete this section �check box if this section does not applv 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)) :�1ame 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 sigizing this fornt,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be proeessed. Submitting a false claim can result in prosecution. Date form was completed ��1 l� Print the Name of the Person who Completed this Form: �� 1_� � Signature of Person Making the Claim: ` � Revised February 2011 I I FF BELZE � CUSTOMER #: 2092944 586609 �� CHEVROLET �� DODGE *INVOICE* KI1► DUSTIN LEE WILSON Highway 50&Cedar Ave. PO Box 965 1716 5 GANNON WAY W Lakeville, MN 55044 ROS EMOUNT, NIl�I 5 5 0 6 8-513 8 PAGE 1 Phone: 952-469-4444 HOME:612-7 2 0-4 8 4 2 CONT:612-7 2 0-4 8 4 2 Fax: 952-469-5232 BUS: 952-997-5608 CELL: SERVICE ADVISOR: 861 JOSHUA A DEYO CA[,QR Y£AR MR[��INI�DEL > �t(hl ;::: LICENS� 11AfL�AG�1f�f::[)�.l'�' ': TA� :: HEADER O 14 DAIMLER DODGE DART 1C3CDFBB6ED669946 302MPW 1 1 3335 �EL.t�Al'E PRQR<[7AT� uv�tRR. E�4P. PRC)I�l15�D > <;: �!:P1C1. ;',: RAT� �A'YI�I�NT;: ;: ENiI £3�T� ; * 11NOV13 D 19 :00 12MAR14 0 . 00 CASH 12MAR14 R,p,',CYp�N�b 't��t�Y:;i >: OPTIONS: STK:D4590O1 ENG:2 .4 Liter TRN:DA4 12MAR14 12MAR14 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL Tk ::�I3STOM�� '.�TA�ES ��IR 4�'! T�iF�R TIR$S ATaFW QU� 1�+TH��r�:>D�TV..:�N�a - AD�T�►�i$ > _ ! TIRElD Replaced 1 Tire - DODGE � �4a�2 GDM ! 2� . 00 < �0.�0 1TD Recycling/Disposal Fee - 1 Tire 2 00 2 00 >! 1 TIKT�,��?�1143: K�2!5�k5I,7 _ '14�.`TO 1�3 ?� i143 .:'7�! DOT K2X5YAL84713 j STS�� ** $15.tJ t3 ii��'F` �* ,7�!f� B��.��=s Cz�ugorr;t Bzxo� 1 VALUE COUPON '�(3t30� ��i� �5 ::00 1,5.:�Q 1 FOUND RIGHT FRONT TIRE TO HAVE LARGE HOLE IN THE SIDEWALL OF THE TxRE. i'RI�I :HAS :S�CURFIT�T4 i�� I�AM�GE T4 ;THE QUTER BEAL> StJhF.A�E; MQUNTEU' AND BALANCED NEW RIGHT FRONT TIRE. �rs��**��>+��r�**�a��r�x�*�+�:*a��c�*�ar*�r+kx*��r:�r�,�x�+k�a��a�,��r,�*?��a��i »s >: >: , B Courtesy Multi-Point Vehicle Inspect�.on s< DODGE » _ ' �t7��: ! Courtesy; Mu3.�i:-Point Vehicle� Inspectior� « DODGE » ` � � 9KD Courtesy Mu�ti-Po'lnt Vehic�e��s��cta�on « ��b��; g��`� �;� . ;` :DODGE >> �. � " �� ,w� #: < , � 3�9 CDI�._ �=- � � - �� ; ' � �� _�i .t30 0 `00 _ _ *�****��**************�***�*�:�*�"**********��r�r��,*��x '_ -.. JB CHEURQI�ET $15.,Q0 �FF � , : 1?ISCOTJi�T COL7PON HA� 'BEEN ' �� _ __ . APPLIED TO LINE "A" ** � _ � ; _ _ _ _ _ _ __ i : ,, , _ _ � _ _ _ � THE ONLY WARRANTIES APPLYING : :�,,[j�$�E{�p3'.'�QE+1 � ��!4�� TO THIS PARTIS)ARE THOSE WHICH ' � � � ' � i MAY BE OFFERED BY THE LABOR AMOUNT S.O O � COMPLETE SATISFACTION MANUFACTURER.THESELLING PARTSAMOUNT 143 .70 � DEALER HEREBY EXPRESSLY DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, GAS,OIL,LUBE O.O O INCLUDING ANY IMPLIED I S O U R G OA L! WARRANTIES OF MERCHANTABILITY O .O O P�RPOSEEAND NEITHERRASSUMES SUBLET AMOUNT NOR AUTHORIZES ANY OTHER MISC.CHARGES 2 .OO PERSON TO ASSUME FOR IT ANY '� CALL 4V.7-373� WITH ANY CONCERNS. LIABILITY IN CONNECTION WITH THE TOTAL CHARGES ZSO .7O I SERVI�E.BUYER SHAL�L NOT BE ENTITLED TO RECOVER FROM THE LESS INSURANCE O .OO �I SELLING DEALER ANY SALES TAX ZO .24 � CONSEQUENTIAL DAMAGES, � (S�GNEDI CUSTOMER SIGNATURE (DATE1 �OR OSS OF USEEROSS OF TAMES PLEASE PAY -- �'� < � � ANYSOTHERRNCIDENTAL DAMEQGES. THIS AMOUNT �� ' �� .6.t3:�� , Copyright 2000 AOP,Inc.SERVICE INVOICE J2 X512C CII3TOM13R PAY � FF BELZE + � CUSTOMER #: 2092944 586760 µ �� CHEVROLET � DODGE - � *INVOICE* K11► � ;, DUSTIN LEE WILSON Highway 50&Cedar Ave. PO Box 965 `'{ 1716 5 GANNON WAY W Lakeville, MN 55044 ROS EMOUNT, NR�T 5 5 0 6 8-513 8 PAGE 1 Phone: 952-469-4444 '"! HOME:612-7 2 0-4 8 4 2 CONT:612-7 2 0-4 8 4 2 Faac: 952-469-5232 BUS 952 997-5608 CELL: SERVICE ADVISOR: 861 JOSHUA A DEYO � �flLQfi Y�R MAK�lM�t�EL <: Vi�t :: tiC�NS� MILEA:GE fht I;��1� 7A�: � , HEADER O 14 DAIMLER DODGE DART 1C3CDFBB6ED669946 302MPW 2367 2367 3350 s, L?EL, DATE PR4D t)ATE WARFi EXP. AR€JfV1fS�D :: Pf�i NtJ >HA'T'E :: PAYMEh1T: tN11 ;t�A�'� ";i _ rj � 11NOV13 D WAIT 12MAR14 0.00 CASH 12MAR14 ;� ' RO;;aP��1�A ;>R�i4f?Y;';:. !: OPTiONS: STK:D459001 ENG:2 .4 Liter TRN:DA4 — h� ;� 12MAR14 12MAR14 �f LINE OPCODE TECH TYPE HOURS LIST NET TOTAL � A F�2.Q�T T�RI�TER IS�DE ;TIRE'< HA� ;BLUD�E II� T�RE ;F�O�:;AFT£R ��:�tE REPLCAEMENT ON RO# 586609 - HAD FRONT PASS SIDE TIRE REPLACED -A �+.FTER BLC?W QUT CRtTSED B3�';:PC�'T HE�LL ;�- F <i Uk2V'ER S�1�E TIRE BAN#)'; HAS SNAPPED - LIKELY CAUSED BY POT HOLE IMPACT " `��hE1D' R�P:�.ac�d 1 Tire �- D�i�GB ; ; ; ,. 20023 CDM 20 . 00 20 .00 � �TD Re�c��.ngl��.�gcisa�. �`e� -- �. Ti;re �.>aa 2 :i�a 1 TKU2141103 K2254517 143 .70 143 .70 143 .70 ��:�XA.L84613! _ _ JB15 ** $15 .00 OFF ** Jeff Belzer's Coupon Book V�LUE, iGOUP4N ;: 20023 CDC -15 .00 -15 .00 ^�i3�7 I�ISMt3UN'S'El� aLT� "1x�1�E. R.�MOX7N�'EDAN� SALAt�I'�EU NET� TIhTs_ 'i _ ***************************************,r************ � ?** �HE $15 .Oa, Q�'F JB: CHEV �,,., : . .,�,..., : _ DISCOUNT CflUPON HA5 Pr I,READY `'�:: �'��° �'' , � k..� e,, 'BEE�>'APPLIED TO LINE "A° ** _. �;.: y -� ;� I a - - , ;: , �: _.. _ _: _ _ _ __ �� THE ONLY WARRANTIES APPLYING ` p�$�'EGfP'�I�P) � TQ3'�!�*c+ TO THIS PART(SI ARE THOSE WHICH �� ' MAY BE OFFERED BY THE LABOR AMOUNT S . .O � COMPLETE SATISFACTION MANUPACTURER.THESELLING DEALER HEREBY EXPRESSLY pARTS AMOUNT 143 . �O � DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, GAS,OIL, LUBE O .O O INCLUDING ANY IMPLIED a I S O U R G OA L! WA`RRANTIES OF MERCHANTABILITY O .O O '� pURPOSEEAND NEITHER ASSUMES SUBLET AMOUNT ,,>� PE SON TO ASSUME FOR ITHANY MISC.CHARGES 2 .OO CALL 469-3731 WITH ANY CONCERNS. `"'B�`�TY�"`°""E`T�°"W�T"T"E TOTAL CHARGES i5o .�o I SALE OF TH�S PARTISI AND/OR SERVICE.BUYER SHALL NOT BE LESS INSURANCE O .O O- ENTITLED TO RECOVER FROM THE �" SELLING DEALER ANY SALES TAX 1 O .24 - ` CONSEQUENTIAL DAMAGES, - ISIGNED) CUSTOMER SIGNATURE IDATE) �OR LOSS OF USEEROSS OF TAMES PLEASE PAY ANYSOTHERRNCIDENT IAL DAMEQGES. THIS AMOUNT c �y ��: ��.l�r'�`� {� � CopV��9M1t 2000.4DP,Inc.$EflVICE INVOICE A2 X512C CII3TOMER ��1 „%�� qt i '�� .��;i± . .,�, :��3 . � I� ,� ;� Warranty on Replacement Parts and Accessories � `• Warrants that (1) for a period of 12 months after sale of new replacement Parts and Accessories " over-the-counter", or (2) within 12 months or 12;000 mites, whichever first occurs, after installation thereof by our dealership on a motor vehicle, it will repair or furnish a replacement part for ,: any defective or malfunctioning part or accessory. This warranty covers only repairs or replacements made necessary due to defects in material or workmanship. It does not cover conditions resuiting - from negligence, alteration, accident, or use for which the part or accessory was not designed or approved; loss of time, inconvenience, loss of use �. of thevehicle or other consequential damages;or labor for removal from the vehicle and reinstallation or a pan or accessory sold "over-the-counter". Repairs qr replacements qualifying under this warranty will be performed by our dealership within a reasonable time following delivery of the ' malfunctioning part or accessory to our place of business. Dg#eGtiY@.or malfunctioning parts or accessories must be delivered to our dealership's place of business during regular hours for warranty repair or replacement. Our dealership must be furnished with the purchaser's copy of the original sales slip on counter sales, or purchaser's copy of the repair order on dealer instaliations,to validate date of purchase and vehicle mileage, as applicable. THIS IS tHE ONLY EXPRESS WARRANTY APPLICABLE TO OUR SERVICE REPLACEMENT PARTS AND ACCESSORIES, AND OUR DEALERSHIP NEITHER ASSUMES NOR AUTHORIZES ANYONE TO ASSUME FOR IT ANY OTHER OBLIGATION OR LIABILITY IN CONNECTION WITH SUCH PARTS AND ACCESSORIES. Implied warranties "Consequential damages: Purchaser shall not be entitled to recover from dealer any consequential damages, damages to property, damages for loss of use, loss of profits or income, or any other incidental damages." REPAIRS USING NON-OEM OR USED PARTS ARE WARRANTIED BY THE AFTERMARKET SUPPLIER, MONTHS AND MILES VARY, AS - ` DETERMINED BY SUPPLIER, (INCLUDES PARTS ONLY, NO LABOR IS INCLUDED►. �� r' MO�AR PARTS & ACCESSORIES MOPAR warranties do not cover the costs of repairing damage or conditions caused by fire or accident, by abuse,negligence,or misuse(for example,driving PRODUCT WARRANTY COVERAGE over curbs,or overloading or racing the vehicle); by improper adjustment, alteration,or failure to maintain the vehicle on which they are installed,or corrosion MOPAR'S Basie Limited Warranty or damage caused by the use of caustic materials. MOPAR Limited Warranties do .'; not cover the costs of damage caused by environmental factors or Acts of God. 1. DEALER INSTALLED PARTS AND ACCESSORIES 12 months or 12,000 miles. ^Environmental factors" include such items as airborne fallout,chemicals,tree sap, The MOPAR Basic Limited Warranty warrants MOPAR Parts and Accessories, salt,ocean spray,and road hazards. "Acts of God" include such things as hail, except MOPAR Performance Parts and Accessories,(shown by MOPAR part floods,windstorms,lightning,tornadoes,sandstorms and earthquakes. numbers which begin with the letter"P")against defects in workmanship or materials installed on a Chrysler Corporation vehicle by an authorized Chrysler MOPAR Warranties do not apply to parts installed on a vehicle which has odometer Corporation Dealer,for 12 months or 12,000 miles from the original installation or emissions systems tampered with or disconnected,or which has been declared ' date;whichever occurs first. MOPHr'?Par#s and Accessories added tc a vahiele to be a totai loss by any insurance corrrpany,or is rebuilt after being declared to be befnre delivery to a retail customer are covered by the 3 year/36,000 mile Basic a total loss,or is issued a certificate of title indicating that it is designated as New Vehicle Warranty. "salvage," "junk,""rebuilt,"or words of similar import. MOPAR Patts and Accessories replaced on a Chrysler vehicle still covered by the Chrysler will deny warranty coverage without notice if it finds that a vehicle is Basic New Vehicle Warranty are warranted for the remainder of the Basic New ineligible for warrenty coverage because it has been salvaged or declared a total Vehicle Limited Warranty,or for MOPAR's Basic Warranty of 12 months or loss as set forth in this paragraph. 72,000 miles from the original installation date,whichever is more favorable to the customer. MOPAR Limited Warranties do NOT cover any incidental or consequential damages connected with the failure of the part under warranty.Such damages include lost 2. PARTS AND ACCESSORIES SOLD"OVER THE COUNTER"- 72 Months.The time;inconvenience;the loss of the use of your vehicle;the cost of rental cars; MOPAR Parts and Accessories Limited Warranty warrants parts and accessories gasoline,telephone,travel or lodging;the loss of personal or commercial property; sold "over-the-counter" against detects in workmanship or materials for a period or the loss of revenue.Some states do not allow the exclusion or limitation of of 12 months, regardless of mileage,except MOPAR Performance Parts and incidental or consequential damages,so the above limitations or exclusions may Accessories.Warranty starts on date of purchase. not apply to you. The MOPAR warranties DO NOT cover the labor involved in removing parts and III.OTHER TERMS. To the extent allowed by law, any implied warraniies, including accessories and/or replacing MOPAR Parts and Accessories sold any implied warranty of inerchantability or fitness for a particular purpose,are "over-the-counter." limited in duration to the duration of these express warranties.If the parts are r"'-, 3. ADDITIONAL INFORMATION.MOPAR's Basic Warrant covers the cost of towin �nstalled on a vehicle used primarily for business or commercial purposes,no Y 9 implied warranties apply. a vehicle to the nearesi Chrysler Corporation Dealer,when the failure of a covered Some states do not allow limitations on how long an implied wananty lasts,so the part causes the vehicle to be inoperetive. above limitations may not apply to you. If a MOPAR part is installed by a Chrysler Corporation Dealer,and if,while that These warranties are the only express warranties made by Chrysler for MOPAR part is still under warranty,it causes other parts to be damaged or to fail,those Parts and Accessories.NO person,including a Dealer or employee of Chrysler,has parts will be repaired or replaced under warranty,regardless of whether the other the authority to vary or change these wartanties. parts were covered by a Chrysler warranty at the time of failure.A MOPP,R part used to replace a failed MOPAR part still under warranty is covered only for the 7hese limited wartanties give you specific legal rights and you may also have other remainder of the replacement part's existing warranty. rights which vary from state to state. r 7. HOW TO OBTAIN MOPAR WARRANTY SERVICE.Where both parts and labor are The following products have separate warranty statements.This warranty does not k covered,warranty repairs, including parts and labor,will be made by any Chrysler apply to them: Corporation Dealer at no charge using new or remanufactured components.Where parts only are covered,any Chrysler Corporation Dealer will provide replacement -Air Conditioning System parts at no charge. It is recommended that you take your Chrysler Corporation -Battery vehicle to your selling Dealer or to the Dealer who sold or installed your MOPAR -Catalytic Converter �.^ part or accessory. However,you may obtain replacement parts or service under -Engine Assembly - warrenty from any authorized Chrysler Corporetion Dealer.Except in an -Master Shield Protection Products - emergency, warranty service for MOPAR Parts and Accessories may be obtained -Sheet Metal ONLY at an authorized Chrysler Corporation Dealer. -Muftler,Shock,Strut,Bed Liner {• ` II. WHAT IS NOT COVERED. MOPAR warranties do not cover any non-Chrysler or MOPAR Performance Parts(parts with MOPAR pan numbers beginning with "P") ;a., Non-MOPAR parts,components or equipment,such as a non-MOPAR radio or are sold as is without any warranty whatsoever.See your Dealer for copies ot each speed control.These warranties also do not cover the costs of any repairs or MOPAR Limited Warranty. adjustments that might be caused or needed because of the use or installation of non-Chrysler or non-MOPAR parts,equipment,material or additives. ��.:, : ��, r-. �"' �- . _- - -. F B E LZE � ;-R cr��v�o�E�r 5 8 6 6 0 9 �� g�,�..t CHEVROLET 21111 CEDAR AVE. DODGE �pK�VII,LE, MN 550� ��:�.�7 *INVOICE* K1A � Highway 50&Cedar Ave. PO Box 965 03�121�014 pppQ�000��19141 Lakeville, MN 55044 Merchant ID: / ��317�9 PAGE 1 Phone: 952-469-4444 Terminal ID: E 8 4 2 Fax: 952-469-5232 376�46146991 SERVICE ADVISOR 861 JOSHUA A DEYO CREDIf CARD vir� ��c�►us� > n��,a��i�f;ou�r �a� ;> P�1CSALE r 1C3CDFBB6ED669946 302MPW 1 1 3335 �XXXXXXX)(XXX96Q9 €inn�s�o t?Q htfl ��t'r�' ��►u��r > i�v 'c��r� CARD# 586609 _. ! .. ; . INVOICE �Q�68 ► 12MAR14 0 .00 CASH 12MAR14 - Batch#: 15`�� ioNS: STK:D459001 ENG:2 .4 Liter TRN:DA4 qpproval Code; SN�iped — , - Entry Method: Onllne AMode; LIST NET TOTAL SAIE AMOUNT $160,g� ,GES �v�� vuT �� - ��s� ,> �o. o� �o:�o _ _ _ _ ___ _ . - 1 Tire 2 . 00 2 . 00 _ _ __ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ __ _ _ ....... _ _ _ .... . ___ CUSTOMER COf'( _ 143 ;:;74 i!;14�.,''7'0 ,'143 :>7.D - _ _ ... .......__....._ ..:. __... .. � �e1z�x r s �flupox� 8�ci� _ _ _ _ ____ _ __ _ _. . ... _ . _ ,�c�t�0�^ �C�� > �.5,(�� 1�,i0t� :.. .. 1 FOUND RIGHT FRONT TIRE TO HAVE LARGE HOLE IN THE SIDEWALL OF THE 'T21�E. ;hIM :.!HAS S�tIFE?ING AI+1D I7�MA�E 'I`C�:;THE !E�UTER BEAD �Uf�`1��E:. .MdU1+�TBb: AND BALANCED NEW RIGHT FRONT TIRE. �a��k�*�:��*>**a��ra�*��.*;��a�,��**a�#::�*��,��*��t�;��,k*�<�k��+�;* B Courtesy Multi-Point Vehicle Inspect�,pn ,<�DODGE » .. GAUSE. ;! Courtesy Mult;i-Point Vehicle Inspection « DODGE » _ 9KD Courtesy Muiti--Point Vehicle �nsge�tion « " � : DODGB » ;a�: �,. 999 CDM � ��.�0 0 .:'�p ***�a��.�:**************��r�*:�*�**�*'*********�,r��*�*�r,�;* ** JB CHE�7R(3LET $15 Oz�J �FF � ,... , ]��SCfJLTi�TT COT,7PO1�T HP;�'v �E��?T _ �a , ,; APPLIED TO LINE "A" ** _; _,. _. �� .. _ _ _ _ _ �'' � 2��` � � + 4 . . . . . . . . ��•r,ti. THE ONLY WARRANTIES APPLYING :�: � ��„"��p�� ::: 7'Q'(`jk�$ TO T:�IS PART(S)ARE THOSE WHICH " , MAY BE OFFERED BY THE LABOR AMOUNT S . O�O COMPLETE SATISFACTION MANUFACTURER.THESELLING DEALER HEREBY EXPRESSLY pARTS AMOUNT DISCLAIMS ALL WARRANTIES, 14 3 .7 O EITHER EXPRESS OR IMPLIED, GAS,OIL,LUBE INCLUDING ANY IMPLIED O .OO � I S O U R G OA L! WAFRANTIES OF MERCHANTABILITY O .O O OF FITNESS FOR A PARTICULAR SUBLET AMOUNT P NOR AUTHORIZES ANY OTHERES MISC. CHARGES 2 .O O � � PERSON TO ASSUME FOR IT ANY CALL 469-3731 WITH ANY CONCERNS! LIASALEOFTH�SPARTISN ND/ORHE TOTALCHARGES 150 .�0 SERVICE.BUYER SHALL NOT BE �ESS INSURANCE O .OO ENTITLED TO RECOVER FROM THE CONSEQUEN�AL DAMAGES, SALES TAX 1 O .`L'�[} (SIGNED) CUSTOMER SIGNATURE IDATEI �ORLOSS OF U�EELOS§OF TIMES PLEASE PAY ANYSOT�HERRNCIDENTAL DAMQGES. THIS AMOUNT :��.�Q �`�� Copyright 2000 ADP,Inc.SERVICE INVOICE R2%512C CIISTOMER PAY � � �� .. 1 . t�y. . ... _ . ; .�� Warranty on Replacement Parts and Accessories " Warrants that (1) for a period of 7 2 months after sale of new replacement Parts and Accessories " over-the-counter", or (2) within 12 months or � 12,000 miles, whichever first occurs, after installation thereof by our dealership on a motor vehicle, it will repair or furnish a replacement part for � : any defective or malfunctioning part or accessory. � { This warranty covers only repairs or replacements made necessary due to defects in material or workmanship. It does noT�►�ver conditions resulting � from negligence,alteration, accident, or use for which the part or accessory was not designed or approved; loss of time, inconvenience, loss of use � of the vehicle or other consequential damages; or labor for removal from the vehicle and reinstallation or a part or accessory soid "over-the-counter". Repairs or replacements qualifying under this warranty will be performed by our dealership within a reasonable time following delivery of the ; malfunctioning part or accessory to our place of business. � Defective or malfunctioning parts or accessories must be delivered to our dealership's place of business during regular hours for warranty repair or � replacement. Our dealership must be furnished with the purchaser's copy of the original sales slip on counter sales, or purchaser's copy of the repair ! order on dealer instal�ations, to validate date of purchase and vehicle mileage, as applicable. � � THIS IS THE ONLY EXPRESS WARRANTY APPLICABLE TO OUR SERVICE REPLACEMENT PARTS AND ACCESSORIES, AND OUR DEALERSHIP NEITHER A$SUMES NOR AUTHORIZES ANYONE TO ASSUME FOR IT ANY OTHER OBLIGATION OR LIABILITY IN CONNECTION WITH SUCH PARTS AND ACCESSORIES. Implied warranties "Consequential damages: Purchaser shall not be entitled to recover from dealer any consequential damages, damages to property, damages for loss of use, loss of profits or income,or any other incidental damages." REPAIRS U.SING NON-OEM OR USED PARTS ARE WARRANTIED BY THE AFTERMARKET SUPPLIER, MONTHS AND MILES VARY, AS ' D'ETERMINED BY SUPPLIER, (INCLUDES PARTS ON�Y, NO LABOR IS WCLUDED►. f' MOPAR PARTS & ACCESSORIES MOPAR warranties do not cover the costs of repairing damage or conditions caused by fire or accident, by abuse,negligence,or misuse(for example,driving " PRODUCT WARRANTY COVERAGE over curbs,or overloading or racing the vehicle); by improper adjustment, �, alteration,or failure to maintain the vehicle on which they are installed,or corrosion I or damage caused by the use of caustic materials.MOPAR Limited Warranties do MOPAR'S Basic Limited Warranty not cover the costs of damage caused by environmental factors or Acts of God. � 1. DEALER INSTALLED PARTS AND ACCESSORIES 12 months or 12,000 miles. "Environmental factors" include such items as airbome fallout,chemicals,tree sap, The MOPAR Basic Limited Warranty warrants MOPAR Parts and Accessories, salt,ocean spray,and road hazards. "Acts of God"include such things as hail, except MOPAR Performance Parts and Accessories,(shown by MOPAR part floods,windstorms,lightning,tornadoes,sandstorms and earthquakes. numbers virhich begin with the letter"P")against defects in workmanship or materials installed on a Chrysler Corporation vehicle by an authorized Chrysler MOPAR Warranties do not apply to parts installed on a vehicle which has odometer Corporation Dealer,for 12 months or 12,000 miles from the original installation or emissions systems tampered with or disconnected,or which has been deFls'tred dete,vahichever occurs first.MOPAR Parfs and Accessories added to a vehicle to be a total loss by any insurance company,or is rebuilt after being declared to be before delivery to a retail customer are covered by the 3 year/36,000 mile Basic a total loss,or is issued a cercificate of title indicating that it is designated as NBdv'V�hicke Warranty. "salvage," "junk,""rebuilt,"or words of similar import. I IvIQPAR'Parts ahd Accessories replaced on a Chrysler vehide still covered by the Chrysler will deny warranty coverage without notice if it finds that a vehicle is � Basic New Vehicle Warranty are warranted for the remainder of the Basic New ineligible for warranty coverage because it has been salvaged or declared a total Vehicle Limited Warranty,or for MOPAR's Basic Warranty of 12 months or loss as set forth in this paragraph. 12,000 miles from the original installation date,whichever is more favorable to the customer. MOPAR Limked Warrenties da NOT cover any incidental or conseque�tial damages connected with the failure of the part under warranty.Such damages include lost 2. PARTS AND ACCESSORIES SOLD"OVER THE COUNTER" - 12 Months.The time;inconvenience;the loss of the use of your vehicle;the cost of rental cars; j. MOPAR Parts and Accessories Limited Warrenty warrants parts and accessories gasoline,telephone,trevel or lodging;the loss of personal or commercial property; sold "over-the-counter" against defects in workmanship or materials for a period or the loss of revenue.Some states do not allow the exclusion or limitation of of 12 months,regardless of mileage,except MOPAR Performance Parts and incidental or consequential damages,so the above limitations or exclusions may Accessories.Warranty starts on date of purchase. not apply to you. The MOPAR warranties DO NOT cover the labor involved in removing parts and III.OTHER TERMS. To the extent allowed by Iaw,any implied warranties, including accessories and/or replacing MOPAR Parts and Accessories sold any implied warranty of inerchantability or fitness for a particular purpose,are "over-the-counter." limited in duration to the duration of these express warranties. If the parts are installed on a vehicle used primarily for business or commercial purposes,no 3. ADDITIONAL INFORMATION.MOPAR's Basic Warranty covers the cost of towing implied warranties apply. a vehicle to the nearest Chrysler Corporation Dealer,when the failure of a covered Some states do not allow limitatio�s on how long an implied warranty lasts,so the part causes the vehicle to be inoperative. above limitations may not apply to you. If a MOPAR part is installed by a Chrysler Corporation Dealer,and if,while that These warranties are the only express warranties made by Chrysler for MOPAR part is still under warranty, it causes other parts to be damaged or to fail,those Parts and Accessories.NO person,including a Dealer or employee of Chrysler,has parts will be repaired or replaced under warranty, regardless of whether the other the authority to vary or change these wananties. parts were covered by a Chrysler warranty at the time of failure.A MOPAR part used to replace a failed MOPAR part still under warranty is covered only for the These limited warrenties give you specific legal rights and you may also have other I- :; remainder of the replacement part's existing warranty. rights which vary from state to state. °"� 7. HOW TO OBTAIN MOPAR WARRANTY SERVICE.Where both parts and labor are The following products have separate warranty statements.This warranty does not covered,warranty repairs,including parts and labor,will be made by any Chrysler apply to them: • Corporation Dealer at no charge using new or remanufactured components.Where parts only are covered, any Chrysler Corporation Dealer will provide replacement -Air Conditioning System parts at no charge.It is recommended that you take your Chrysler Corporation -Battery vehicle to your selling Dealer or to the Dealer who sold or installed your MOPAR -Catalytic Converter �- part or accessory. However,you may obtain replacement parts or service under -Engine Assembly warranty from any authorized Chrysler Corporation Dealer.Except in an -Master Shield Protection Products 1:,: : emergency, warranty service for MOPAR Parts and Accessories may be obtained -Sheet Metal ONLY at an authorized Chrysler Corporation Dealer. -Muffler,Shock, Strut, Bed Liner II. WHAT IS NOT COVERED.MOPAR warranties do not cover any non-Chrysler or MOPAR Performance Parts(parts with MOPAR part numbers beginning with "P") Non-MOPAR parts,components or equipment,such as a non-MOPAR radio or are sold as is without any warranty whatsoever.See your Dealer for copies of each speed control.These warranties also do not cover the costs of any repairs or MOPAR Limited Warranty. � adjustments that might be caused or needed because of the use or installation of non-Chrysler or non-MOPAR parts,equipment,material or additives. � E � B LZ � F . F E � s �� CHEVROLET DODGE K11� Highway 50&Cedar Ave.• PO Box 965 •Lakeville, MN 55044 I Phone: (952)469-4444 •Parts Direct: (952)469-4448 � Parts Fax: (952)469-5232 DISCLAIMER OF WARRANTIES � Any warranties on the product sold hereby are those made by the manufacturer.The seller hereby expressly disclaims all warrandes,either expressly or implied,including - any implied warranty of inerchantability or fimess for a particular purpose,and the seller neither assumes nor authorizes any other person to assume for it any liability in connecrion with the sale of said producu. i�� NO REFUND WITHOUT THIS INVOICE.ELECTRICAL AND SPECIAL ORDER PARTS ARE NOT RETURNABLE.TORN,DAMAGED,OR SOILED PACKAGES ARE NOT RETURNABLE.NO EXCEPTIONS.NO REFUNDS AFTER 30 DAYS. 30%HANDLING CHARGE ON ALL OTHER RETURNS.ALL PARTS ARE NEW UNLESS SPECIF[ED OTHERWISE. :, .-�i I DATE ENTERED YOUR ORDER NO. DATE SHIPPED INVOICE DATE INVOICE �I 12 MAR 14 12 MAR 14 NUMBER R35298 S **RO QUOTE**S o ACCOUNT NO. 2092944 H PAGE 1 OF 1 L I � DUSTIN LEE WILSON P # 0 17165 GANNON WAY W o � ROSEMOUNT, MN 55068-5138 SHIP VIA SLSM. B/L NO. TERMS F.0.6. POINT 047 14 :27 RO <; ou�wn P}.�R'7" NCl. . ; [�:E'�`��4�PT1:4N ` l;i'�uT.,: . ; r��r ; �anno��v�r ;; HOURS OF ` 09U ::':SHIF R.Q.��.�� .. ......:: ., R!J Quote> �or !Ser�vi�e l��pas:� 4rde `::��55 :9 OPERATION ` Service Advisor: 861 Vehicle: ED6699 6 ;4 Part {S) :c�uoted on Line A CU�T, ER_ST ES Q1�TE OF;. THEIR T SERVICE � 1TH58J��AC 'WHEEL-AL 5�7.6fl 537.�0 537.60 M - TH 0 TT�U21�1I:03 TTREIK.�,254�17 1+�3.�o �.�o ;��ao 6:30A - 7P Parts quoted,a�. RC?# 585609 F a *�*� �t o � !� R �r S , ,,, ;<: ;< ��_' 6:30A - 5:30P !1� ��eO� , ,� QUICK LUBE !J�1 G��'�d V� Vh'c�`�,P.�l► � v M - TH = �. : �`�� o �"��*�.._ 6:30A - 9P _ n e-� a�� F f�-�� ' � � 6:30A - 5:30P � - ' ' - �� - I SAT ��,z�� 8A - 3P a , , ,, < PARTS ` ; ; , ; ' M - TH J�ian�r �ou� 6 0 6:30A - 7 P �e appNe��te : �0 6:30A F 5:30P [�our )0 � aEroi2a Q. CUSTOMER'S SIGNATURE I p � X �arA� , 8A - 12NOON "°"'°°-' CIISTOMER COPY CopY�Sht 2000 ADP,Inc. FANT$INVOICE 1-UP XP13C1 Gmail - Fw: Call History Request Page 1 of 1 � � � Dustin W< dIw024 a�gmail.com> .y�;;�.�.,,�I=,.: Fw: Call History Request Larry Freshwater< Freshwater1@charter.net> Thu, Mar 13, 2014 at 10:05 AM To: DUSTIN WILSON <DLw024@gmail.com> From: Malec , Angela Sent: Thursday, March 13, 2014 8:37 AM To: maiEto:freshwaterl@charter.net Subject: Call History Request Mr. Larry Freshwater, Our records indicate that a service call w�s placed to the Automobile Club of Minnesota, Emergency Road Service Area, on March'11, 2014. This call was for service to a 2014 Dodge Dart. The call was received at 8:19 pm. The servicing facility, AAA Minnesota of St. Paul, Minnesota arrived on location at 9:03 pm. The vehicle was taken to 21111 Cedar Avenue in Lakeville, Minnesota due to a flat tire. The service call reference # is 88099. It is on filed in the Emergency Road Service Area should any questions arise concerning this matter. 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