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Dolan ■ MFDC & MFMC■ Minnesota Financiai Development&Management Corporation 401North Third Street ■ Suite 160 ■ Minneapolis,MN 55401 Ann K. Dolan Senior Vice President / Marketing Director Phone (612)455-4020 ■ Cell (651)592-8874 Fax (612) 455-4060 ■ E-Mail ann@mfdc.com RECEIVED APR 10 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Min�e��t C L E RK Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipaliry 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 prceess 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 �1�(� Middle Initial�Last Name JJ Z��Q'''l Company or Business Name / Are You an Insurance Company? Yes/ o��If Yes,Claim Number? Street Address �9�c' ��i�-`n �4�• City :5�� I`c�-� State �� Zip Code 5 S�d J Daytime Phone(�).�9�- �g 7`�Cell Phone( 5�) S9Z 8�Q 7�Evening Telephone( ) - Date of Accident/Injury or Date Discovered z/r� �� Y�k i3 ti�s��y Time am/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 andlor responsible for your damages. Z �16�YC h�oW�t t;4 4 �f�rc C�l� '�'iq On Cae�;r� .he��.'Ccr� �Iy ' �fi:�tS �� 3 7�N1E5 i�� f� �4'S� 12.�ac�l�is I 1� m�Q �� Q ho�r bl� m�+s� ' 71,r l��k, ��► -(;��-� o� � a f �1�.� 5;'�cl�,, hk a r df{,d1c � �s a Isa � " i a� u �t(a; n C'i r�{; ti, Il l -�at,c af �� -I;r -f fh kt.t �cc�al ! � �' ' �-F t�; +: S ! ? ati ��acLt.n� RIl L>� �fk.� � r.� � l�F �nvGYCt �e, a ►tu: ��:z . 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 vou need to include copies of all auulicable 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 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 andlor 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-please complete this section �. Were there wimesses to the incident? Yes No Unlrn� (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes (�` 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. G'� C�E�i� �� ��u� 9y r ���5��� Please indicate the am�unt you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. �5�. 7 � �7 r l'o;� aF r�,�lQ i�G �i,esQ ���.5 • _ Vehicle Claims-please complete this section ❑check box if this section does not avulv Your Vehicle: Year ��� Make�z Model � License Plate Number S I 7 G�State 1�1 Color t3lc�c K Registered Owner /�nn �a)Q�� Driver of Vehicle ���t l��a�� Area Damaged -E-�r£S K 3 City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injurv Claims-nlease complete this section �check box if this section does not apUly 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 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 y/� /�� Print the Name of the Person who Completed this Form: flil �a��-�� Signature of Person Making the Claim: � �� Revised February 20l 1 in Service Center Repair oraer#0031250 arshall Ave �ate : 4/5/14 ' MN 55104 Page : 1 �L i1V?'v�thGll��`,k,N61 i ''`C - � L�r,� + .,} �:?!- Center : ;� :�1�, , ��Gj,; x� t 4- 436 `n� `"'��a �INAUTO.COM * O � S 4,'�l�Ut`-] yr�n` , ,r�ir;- rrLL-� �t l�;F'F ril"I,i; 1,�, ;�r,h F{"'�.._`'�'�° Vehicle : 2009 MAZD 6 SERIES �;1.F'Hi_I'i. ;�i�! '`:`',��,�=� - License : 817GNA Sub : '-":��'';' 'r�'"� VIN : 1YVHP826395M07879 �'� Engine : V6-3726 3.7L DOHC Trans : AUTO ti�j'�_h � 1;'il ,� hr�.i � ��t�... . �;i�;Nta Mileage : 88691 HUiH � ' v L�Fi r��_�_�}��ra� # k.Xh` Ur1 i r- k k 4 ,I%k� y t�;�y;� Labor Parts Subtotal ,�l k, Y `-•• z° �scriqtion Reason for Replacement Price �h i."..t. �1 .� i l...i H�t r�!`''�`�'�, i 15.00 164.32 199.32 y,�4t� +`_`� r+� �Ht t'lr ,C_ H�n!1;1141 SERVICE hIT 9.95 hl..�_.11h11i1•dt i'� -:f"'hL' '-�'��F� F'EE 3.00 �++,_;�t�tl"Fra1 wElcxTS i .3e h i_��F�y AL G-MA}: AS-03 1h9.99 'i.,_''i.l�l� . OK Bad Recommendation OK Bad Recommendation OK Bad Recommendation I hereby authorize the repair work to be done along with the necessary parts Labor: $15.00 and materials, and hereby grant you and/or your employees permission to Parts: $181.32 operate the vehicle herein described on streets, highways or elsewhere, at Sublet: $0.00 your descretion, £or the purpose of testing and/or inspection. An express OtherFees: $3.00 mechanics lien is hereby acknowledged on the above vehi,cle to secure the Supply ChBPg $10.74 amount of repairs thereto. I understand that dealer/owner is not responsible Subtotal: $210.06 £or delay or other consequence due to the unavailability of parts shipments Sales Tax: $13.83 beyond theircontrol. Not responsible for damage or articles left in car in case o£ £ire, theft or any other cause beyond our control. Pa�d By' TO�I: $223.H9 WARRANTY IS 18 months OR 18,000 MILES WHICH EVER OCCURS FIRST, UNLESS pay Ref: P81d: $O.00 SPECIFIED OTHERWISE! Due: $223.89 X � , + Customer History Report � Marshall Cretin Service Center 2178 Marshall Ave St. Paul, MN 55104 651 644-3436 * MARSHALLCRETINAUTO.COM * O-C-S Report printcd on �/4/2014 at 7:12:59PM Page 1 of 2 For the Period 4/4/2004 to 4/4/2014 Customer Information Vehicle Information Customer: DOLAN,ANN Vehicle : 2009 MAZD 6 SER[ES Address: 1930 JEFFERSON AVENUE License : 817GNA City,State Zip: SAINT PAUL, MN 55105- VIN : I YVHP82B395M07879 Phone 1 : (651) - Ext : Engine : V6-3726 3.7L DOHC Sub : Phone 2 : (651)592-8874 Ext : Trans : AUTO Highest mileage: 73,697 Parts cbsts: $397.82 Cost per mile driven : $0.04 Lowest mileage: 61,286 Labor costs: $64.25 Miles driven : �� Other costs: $56.81 Total costs: $528.88 Repair Order: 0027304 Writte : 2/13/2013 Closed : 2/13/2013 Mileage: 61286 Parts Quan Part Number Description Price Op Tech Description Price 1 20030 TPMS SERVICE!'KIT$12.95 TIR005 527 MOUNT& BALANCE ONE TIRE I5.00 2 WW WHEEL WEIGHrTS $1.38 COM005 527 TECHNICIAN NOTES: RIGHT/REAR 0.00 1 2354518 GENERAL GMAX A$195.99 TIRE � __- SENSOR VALVE CORE WILL NOT MOVE. COULD NOT ADD AIR, BUT ACCORDING TO THE SENSOR OUTPUT, IT IS AT 32 PS! Repair Order: 0027884 Written • 4/20/2013 � � Closed: 4/22/2013 Mileage: 65032 Parts a or Quan Part Number Description Pyiee—� Op Tech Description Price 2 W�r WHEEL WEIGHTS�1.38 � TIR005 527 MOUNT& BALANCE ONE TIRE 15.00 1 2354518 GENERAL GMA A$195.99 COU019 527 Post Card Discount$5/5% -0.75 1 DISC PART D[SCOUN ($9.87) � Customer History Report Report printed on 4/4/2014 at 7:12:59PM Page 2 of 2 ^ Repair Order: 0029243 Written: 9/1 1/2013 Closed: 9/12/2013 Mileage: 73697 Parts Labor Quan Part Number Description Price Op Tech Description Price COMO 527 check brakes--grinding noise. 0.00 BRK005 527 BRAKE [NSPECTION - 35.00 Includes- Road test vehicle,measure& record brake rotors, pads and shoe thickness and brake drum diameter. Inspect brake hydraulic system. front brakes are around 20%wom. rear brakes are around 35%worn. all other hydraulics and hardware appear okay at this time. there is a slight noise when in motion that resembles a tire and/or wheel bearing noise,but none of the bearings are loose. no services needed at this time.