Fishbein �E�EiVED
APR 04 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Mirtdh��LERK
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body qf the municipality within !80 days after the alleged loss nr injury is discovered a notice stating the time,place,and
crrc��m.rtunces thereof,und the umount of compensation or other relief demunded."
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 e�eplain 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 dces 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 �ZS�P N Middle Initial � Last Name F�SHQ���
Company or Business Name �✓� /4
Are You an Insurance Company? Yes/�IV� If Yes,Claim Number?
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Street Address /v yZ /1 UN1!'J��T ./J'�'C�
City �✓�� �• .����- State M/�� Zip Code-�-s/��
Daytime Phone(����)3��- �S�-i' Cell Phone (��I )?�-�6y`� Evening Telephone(�%� )�S%-���v
Date of Accidend Injury or Date Discovered ��2`��z U� �' Time �:/S am�
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 em lo�ees are involved andlor responsibte for your damages.
� ��►�+�u lr /VC/L%�'lu^v(/pi�/1 j�/ /Jy.ro ,��/C L /'_D�>^ //✓ L' 6'LT !�"�� �v< !�
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G✓��tw�ff ti,r��..� � y'cr�c r�� �Y /,✓n��G� � svsr�<<� i�✓,�r r�rE
t�F•,- �r•Da-i t,�(�c'<� r�,�rr waI rt1lS�vG ,G!1/G TN� ,E/,^�l W/'1 �'d�vi.
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
�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 you need to include copies of all 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 ciaims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be relurned.
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 comutete this section �
Were there witnesses to the incident? Yes �No/ Unknown (circle)
Provide their names,addresses and telephone numbers:_�
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 landmark,etc. Please be as detailed as possible. Tf necessary,attach a diagram.�U/�7/J ��,t�^�Q �y�'
�q,t� /�,Up; C-�F�i G/�.•,�f.— r rw�%s IT.ct�!►,^ �I��G itl/'�^C li��F:
Please indicate the amount you e seekin m compensation or what you would like the City to do to resolve this claim
to your satisfaction. �2�G���� 7L r'�� <�- �rn �f k�i�'�n�i�-1��i w�dr��-
A.,/� �,,,N F�� ��JC/'
Vehicle Claims—please complete this section � check box if this section does not appiv
Your Vehicle: Year '--'�� Make TUy�,—�' _Model n"/�T�1�C
License Plate Number ��,: C�=� State r�� Color G��'GF'
Registered Owner ��S Gpl� !"• �ISNP��%✓ _
Driver of Vehicle �S�1.M f'l _ __
Area Damaged L��% f�oN� G���rs�
City Vehicle: Year Make Model
License Plate Number _ State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iqlurv Claims nlease comnlete this section �check box if this section does not annlv
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
�Check here if you are attaclung 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 ��� ��
Jv��PN �9. Fi.lN�'c��n�
Print the Name of the Person who Completed this Form;-^, ^� .� -
,�T
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Signature of Person Making the Claim: � �%T?�� -� �
,
Revised February 201 I „�'
2003 Toyota Matrix—Left Front Wheel Pothole Damage—March 20,2014
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Photo 1. Left front wheel with pothole impact damage (10:00 position)and missing wheel cover.
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Photo 2. Close-up of wheel rim damage.
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Photo 3. Left rear wheel,showing type of wheel covers on the car.
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� RICK&TOM'S�� ***** RETAIL INVOICE ***** � � � �
04/02/14 4 :19 m CASHOl I 60111
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a �'�,t � ��° � '
TIRE 8c SERVICE ' '' '• ' '• '
11375outhRabertStreet 03/24/14 04/o2/i4
West St.Paul,MN 55118
651-450-0535 , • ,
651-450-0537
C JOE FISHBEIN O1 50776
Page : 1
U Vehicle Information
S License : JDD-795
T Make : TOYOTA
O Phone: 651/457-1610
M Model : MATRIX
Year : 2003 ��iJ�� �-
E
R Mileage : 206000.0
Hand Ticket: 60111
User ID: KAU
SALESPERSON: o� xousE sALES PURCHASEQRDFR N0:
� � p • - � �° ���� � 1 •s � � �
NSM NEW STEEL WHEEL LF 1. 00 110.00 0 .00 0.00 110 .OU
NSM USED WHEEL COVER 1.00 65.00 0.00 0.00 65.00
T-TC TIRE CHANGE 1.00 6.99 0.00 0.00 6 .99
T-B COMPUTER SPIN BALANCE 1.00 9._99 0.00 0.00 �9.99
SS SHOP SUPPLIES 1:00 4.00 0 .00 0.00 4 .00
RK SERVICED BY RICK K. 1.00 0.00 0.00 0.00 0.00
Payment Type MASTERCARD 208 .73
195.98
Sub Total
Tax Total 1 z .�s
Amount Due 208 .73
HOMETOWN TIRE�:SERUICE ACC6UNTS RECEIVABLE CONDITIONS
In the event of default in payment when due of any indebtedness created
TERMS ARE STRICTLY 30 DAYS by acceptance of ma�erials and labor provided by Hometown Tire&Service,
10°/ RESTOCKING FEE ON ALL RETURNED ITEMS Hometown Tire&Service shall be entiiled to interest on any such indebted-
p ness irom the date due at the highest legal rate plus attomey's fees and court
NO REFUiVD ON SPECIAL ORDER PARTS OR TIRES costs,should Hometown Tire&Service choose to employ an attomey to collect
any such indebtedness after defauft. iER�S NET 10TH PROX.-MONTHLY
� � ��� .�� 1 RRTE 0�1-1/4 SERVICE CHi+�GE ON PAST DUE RCCOUN�S OR RN 1�NNUAL
� Xv I PERCENTAGE OR i8%
I
--°---°°--°°-°- Cusiomer Signa�we X
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