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Bombardo RECEIVED APR 11 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minif'e��'� CLERK Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the governing body of the municipality within 180 days after the a[leged 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 �Y 2 Middle Initial�Last Name �o�b a r� v Company or Business Name �,Irl i v�Qn 5�1M 0 d V� • � 1-wM�.S Are You an Insurance Company? Yes No� If Yes,Claim Number? Street Address 3 �� 3 r� ST City �� -1 R��S State M�1 Zip Code�� I', Daytime Phone( Sl �i�zr f^�Cell Phone(l�2 )�1 -�Evening Telephone(�a�)�- 31c3C� Date of Accident/Injury or Date Discovered ��/�_Time z-� S am/pm Please state, in detail, what occurred(happened), and why you are submittina a claim. Please indicate why or how you feel the City of Saint Paul or its employees e involved and/or responsible for your damages. ►�a� 6 �re�.r� t�.e . rd h,, ' o� h . �- �re 1,u ` m �I Please check the box(es)that most closely represent the reason for completing this form: I'' ❑ 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 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 conies 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 i 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 i 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 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. If necessary,attach a iagram.�3n l:��n I�-e - �oirw cx�k _ �! .`'�I�w c� `1 ' 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. Vehicle Claims—please comulete this section � check box if this section does not applv Your Vehicle: Year�o\Z Make �1'd o�2 Model uw�r License Plate Number � � St te M ti . Colar �� Registered Owner JM� Driver of Vehicle ��q v r`�- � Area Damaged �� W1�� '� r`'M City Vehicle: Year Make Model ' License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims nlease comnlete this section ❑ check box if this section does not apnlv , 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 I When did you miss work^ _ (provide date(s)) Name of your Employer: Address Telephone , O Check here if you are attaching more pages to this claim form. Number of additional pages i 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. Submittin a alse claim can result in prosecution. Dat f�rm was completed t ` � g f Print the Name of the Person who Completed t 's Form: eb�. �0�2'YC.�C� Signature of Person Making the C ' � Revised February 2011 I 4/9/2014 Gmail-Discoum Tire Web Order Ca�firmation Discount Tire Web Order Confirmation Do-Not-Reply@discounttire.com <Do-Not-Reply@discounttire.com> Mon, Apr 7, 2014 at 9:08 PM To: pjbardo@gmail.com Dear Patrick Bombardo, Thank you for placing your order with us. The details are listed below and we suggest printing this e-mail for your records. Order ld: 5065842 Order Date: 04/07/2014 Product Information: 1 (14482) Bridgestone P�1.r,/.r,.r,R17 G�V RW Turanza EL400 1 (98274)TPMS REBUILD#20032 TQ-40 RED � _. `Total Price: $223.08 --`_ , *** Since you ha�e purchased fewer than four tires (or wlieels), we(nrill mount the new tires on the rear of your �ehicle for best safety and handling. **" Vehicle Information: 2012 TOYOTA CAMRY 17"BASE HYBRID �E (TPMS) Customer Information: Patrick Bombardo Phone: (612)919-7722 EmaiL / Store Information: �� S I�icr.ni int TirP � i 9101 Broderick Bl�ci � �-�� Inver Gmve Hts. MN 5S(l7R (/� YV� T �.�-�, �• � �� To change or cancel your order, please call the store directly. Notice Unforeseen circumstances such as inclement weather, natural disasters, etc. may result in a delay in fulfilling your order. ff such a case arises, please call ahead to the store to confirm they are able to install your product. This message has been scanned for malware by Websense. https://mail.g oog le.corr�maillu/0!?ui=2&ik=1 c6ddc871f&�+ev�pt&search=inbox&1h=1453f166720eaf19&sim1=1453f166720eaf19 1/1 4/9/2014 Grnail-Caifirmation of your order o�2013 Le�s Rirrs 17 Whed Toyota 17"Rim CamryVVheel NEW 69603 Toyota Wheel OEM... Confrmation of your order of 2013 Lexus Rims 17 Wheel Toyota 17" Rim Camry Wheel NEW 69603 Toyota Wheel OEM... eBay<ebay@ebay.com> Mon, Apr 7, 2014 at 8:13 PM Reply-To: ebay@ebay.com To: pjbardo@gmail.com Thanks for your purchase! Here's your order confirmation Hi Patrick, Here is a summary of your recent order. You can also view your updated in My eBay. Thank you for shopping on eBay! Order detai ls You comple#ed checkout on Apr-07-14 Ship to: Payment details: T Patrick J bombardo PayPal $170.00 '�d�,R R� rri Ct Inver Grotie Heights, MN ��n�a i i� Seller: ( �{ ) P�� Shipping �y hem total Item title price 1/mail. Ie.corrJrriail/u/0!?ui=28�i1r1c6ddc871f&uev�pt8�s�rch=iribo�th=1453ee5a719149228�sim1=1453ee5a71914922 1� �Ps= 9�9 � UNIVERSITY of ST.THOMAS University of St. Thomas Student Health Service 651-962-(750 w�vw.stthomas.edu/studenthealth � b w�w� ,� vv� �v�.e�P,�r� . � � - ,�� `-�-� � �� ` � � c1,r� +�,s,,, . � � �� J W� ��n•e. �s�-- 9�.�- �,�S O �m� �irw,n,� �.51- � ' 3�3� e� �� l�.�a- �o� - ��-- �� d-o 3�} c�g g�3� � � . � � �� i.�e�- �� 5��-� Return to Clinic Provider Date_/ /