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Arnott RECEIVED aPR o 7 zo�� NOTICE OF CLAIM FORM to the City of Saint Paul, M�r�el�o�L E RK Minnesota State Statute 466.05 states that"...every person...who clai»ss 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 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 First Name `f,r�� Middle Initial_�.L��t Name____ /l'�•'✓� �� Company or Business Name _�� Are You an Insurance Company? Yes/� If Yes,Claim Number? Street Address �� /�Crv� �� City �� %��' State �� Zip Code '�5��'S' Daytime Phone(�S�)�Zj-�s��Cell Phone(6��) �`�� Evening Telephone(��)^'-zS ��`�`7 Date of Accidend Injury or Date Discovered_��'2�� Time •'UU /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 respon ble for your damages. �.ef�"i�✓� /{/O��.�/ �`�/ /��i�✓.�' /�v�-,/��' ��'`7�✓�—�✓ /1�/��.('h�� D C�--�vc:-��2 / � .��1'��G� U�✓.e�-��iz�� •�c�� i c�-°�� ,�Yv 7 �.�'� ��o�.� ,c�v�,� � ��2✓� �'r�J�if.-�i �. �-f-f-i iJ .�'v�J ii✓ %'i C-��-�� G�rn/�. .�� d 7 ✓' CP.'�+J � � �✓'/✓'7�'1v��-`7 �.%'1i �/-��f7.2� 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 18�My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow 0 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 couies 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. 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�pr 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 tepair estit�ates 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—alease comalete this section Were there wimesses to the incident? Yes � No Unknown (circle) Provide their names,addresses and telephone numbers: Lc�/�`>�✓ ��^"��"'��?_ ��Z� ��'£ �✓� '-7. .��c. /��v Si o v �65�- �1.-cFysa � �f� /�Z��J�1'�� .2..��- ..e�y2^��i 's_s' /?�ij✓��-��✓' �✓N Esi -�s��-5�.��j , Were the police or law enforcement called? Yes �o' 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 landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.��•,�� 'T/� /��Z��-i/�r-£.✓ !'�!-�,f�iS'�_ �'✓D C�s+�/f��A�� 7��7� /Fjf>c�/��-'`z_ f��1/c+�✓ 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. � -� �-3 �� — Vehicle Claims— lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year �� Make ��►'��1 Model 'G��'�� License Plate Number ��S� � State� Color G u� Registered Owner .P��'`�f✓ �- '�'..�� 9�`�-✓ /��'''� �^'°�'� Driver of Vehicle ��-l'�n/ �� "'z�� Area Damaged /��f� ��-�i'7 7"�2- � ��.0 2/�i City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—nlease complete this section check box if this section does not ap� How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes �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 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 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 Narne of the Person who Completed this Form: ✓�� - ��^�a��7 Signature of Person Making the Claim: ��' Revised February 2011 t;ustomer�nvoice TIRES PLUS Service Advisor: 116873 MIDWAY 73 GABE 04/02/2014 300 SNELLING AVE N 651.644.1975 SAINT PAUL, MN. 55104-5330 � 2012 HYUNDAI ELANTRA LIMITED [BLUE] � ARNOTT/BREDESEN, STEPHEN/KATHY 4-1797 1.8L DOHC 1121 HAGUE AVE Lic#: NA MN Vin#: KMHDH4AE9DU529811 SAINT PAUL, MN 55104-6412 In: 04/02/14 8:23AM Mileage: 17,152 651.962.4950 xhers Or 651.470.3383 xhers Out: 04/02/14 4:43PM Store#244226 RETAIL SALE Rev Hist Unit Extended Job Description /Article# ID Qty Price Price Total COURTESY CHECK 73 COURTESY CHECK 7046930 03NS 1 N/C N/C BRIDGESTONE TIRE PACKAGE 1,2 73 177.96 144526 ECOPIA EP422 BL P215/45R17 87W 65,000 Mile 144526 03TN 1 143.99 143.99 Limited Warranty DOT# V6DLE260614 NEW TIRE WHEEL BALANCE PARTS 701870$ 03TN 1 3.99 3.99 NEW TIRE WHEEL BALANCE LABOR 7018716 03NS 1 9.00 9.00 SCRAP TIRE RECYCLING CHARGE (1) 7075078 03TN 1 2.99 2.99 LOW PROFILE TIRE INSTALLATION 7006472 03NS 1 N/C N/C 7040215 ROAD HAZARD WARRANTY 7040215 03TN 1 10.99 10.99 7020K TPMS KIT 6-138 7010680 03TN 1 7.00 7.00 WHEELS 1 73 . 428.99 WHITE BEAR LAKE, BLOOM, BURSVILLE 52103x350 CUSTOM WHEEL 17 INCH DEALER NEW 7000620 03TN 1 428.99 428.99 WHEEL PS FRONT Technician(s): 03 ALEX MILLER Payment History: Summary: Visa 4160 653.08 781175 � Parts 594.96 Total Tendered 653.08 Labar 11.99 Shop Supplies 0.54 Sub-Total 607.49 Tax(7.625%) 45.59 Total $653.08 I have received the above goods and/or services. If this is a credit card purchase, I agree to pay and comply with my cardholder agreement with the issuer. Rev Revision History• Amt Init Customer Signature 1) 04/02/2014 09:48AM 617.04 ARNOTT/BREDESEN, IN PERSON 2) 04/02/2014 04:41 PM 7.53 ARNOTT/BREDESEN, IN PERSON Initial here to indicate you have received the Tire Warranty Maintenance and ' Safety Manual. All parts are new unless otherwise specified. I acknowledge notice and oral approval of an increase in the original estimated price. Signature or Initials PSge 1 01�2 Inv1 130731.402114 Gustomer Invoice TIRES PLUS service Aavisor: 116873 MIDWAY 73 GABE 04/02/2014 300 SNELLING AVE N 651.644.1975 SAINT PAUL, MN. 55104-5330 2012 HYUNDAI ELANTRA LIMITED [BLUE] ARNOTT/BREDESEN, STEPHEN/KATHY 4-1797 1.8L DOHC 1121 HAGUE AVE Lic#: NA MN Vin#: KMHDH4AE9DU529811 SAINT PAUL, MN 55104-6412 In: 04/02/14 8:23AM Mileage: 17,152 651.962.4950 xhers Or 651.470.3383 xhers Out: 04/02/14 4:43PM Store#244226 RETAIL SALE Rev Hist Unit Extended Job Description /Article# ID_ Qty Price Price Total TELL US ABOUT YOUR EXPERIENCE TODAY AND ENTER DRAWING FOR$500 IN SERVICE! Call 1-800-754-9817 or go to www.TiresPlus.com/survey; Enter code 244226-116873 Offer expires 10 days from date of invoice. Good at all participating locations. 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