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Merrill (2) NOTICE OF CLAIM TORM to the City of Saint Paul, Minnesota Minnesnta S�crte Sulhue 466.05 states thnt "...everv persnn...wlin clnims dnn�age.s.from nny murticipnliry....cluill cnuse tn he presented tu d�e gnverning l�or(y of t/re mtinicipnliry mithrn /80 d��v.r after t/1e n(le�ed/oss or injury i.r discor.ered a notice stating the time,pince,anrl circunrstances thereof,ancl the amount of contpensation or other relief demnnded." Please complete this f'orm in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note th.�t you wiil not be contacted by telephone to clarify answers,so provide as much information as necessary to expiain 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 n�ture 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��i J V Middle Initial �J Last Name�>- � J , � l Company or Business Name ` . , ._ ----- -.- � __ _ _ _ �w�.�.,. ___�-._ _,a___..,.g_�^_�._.. Are You an Insurance Company? Yes/�No� If Yes,Claim Number? Street Address 1 G\ � ���'�p-���-� -�t City �� �c•�l State �� � � Zip Code .� -S I� $_ Daytime Phone ( ��)�-�Cell Phone ( )_= Evening Telephone( ) - Date of Accident/Injury or Date Discovered�''l T��' � � ���� Time �3 O am\ pm Please state, in detail, what occurred (happened),and why you are submitting a claim. Please indicate why or how you feel �he City of Saint PaNI or its employees are involved and/or responsible for your damages. V�. G'l,v c- � ( -.lG�S J^yc c��� � i�: c�,:, �►.. lKl ` C I o � � 1C� S6 A.. VE � - ` 'C d Y�11� ' V C ( , i c�2_ C� C L` � k,u�–K- ti.�.; � �a, , �,,y�vp �-}�c�_____`-�����. �,� –I��— �'h,� 4.�� l�l ,.����� �;e�k- ! 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 coAies of all apnlicable 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 �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 I'ailure to complete and return both pages will result in delay in the handling of your claim. All Claims—please complete this section .��-� Were there witnesses to the incident'? Yes R o1 Unknown (circle) Provide their names, addresses and telerhone mbers: � c��w� �.� �:� y�Rv�_ � �- w�,��w h�� �� �, l,��.� ���.� , 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, ete. Please be as detailed as possible. If necessary, attach a diagram. C*- �° � � � � � �..�5._� \J P�/' �°�e,- , s c�1 v�c "n v.`��� ' Please indicate the amount you are seeking in compensation or what you would like th ' " .: to your satisfaction. ������ �l � � Vehid�e C'#aims—pleas�euirrpfc�te trifs�sec�[ton ��i��ccic �� Your Vehicle: Year�G � 2. Make V�1 ks a�. Model�� ��'�o.. �.S�. License Plate Number �'I"l �w Y� State��{ Color��0.G Registered Owner �.Y �( :, v ,r; t� Driver of Vehicle ��s�l,.o►-� �,zJ'v"� \� Area Damaged p��, s�s � �.�, � .� C�;, �t -���e_. - City Vehicle: Year Make T Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniury Claims—please complete this section ❑ check bc How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek T, When did you receive treatment� Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? Name of your Employer: --- -- Tddress Telephone. �/ __`~`�._._._._-.- �s Ye< < ` l�Check here if you are attaching more pages to this claim form. Number of additional pa�es�. �r i � I3y signing this form,yo« are stating tliat all informatiore you lzave provided is trz�e and correct to tlze best of yoicr knowledge. Unsigned forms will not be processed. Submitting a false claim can resitlt in prosecution. Date form was completed�,,,. , � 1 i 2 Q i_�_ i Print the Name of the Person who Completed this Form: �� ,�; ____ , / , i � - Signature of Person Making the Ciaim: - - 1 � Revised Febru�uy 201 I � ���v� c1v� Y����-� i��� 11��e ,s` �tr� ' e� ,v� �S �Q s S-�,,l� � n �l�- ` _ y � � �S"�" bckv.c� �-'X�� ���w�-�� C�1 1 � ,�c:s� c'��� � ve'���, � �1c� 61,� .S�•�vtiw.��, ��t �a �.,�� b��� ���. � �� -� ,� �,��� Clz �r ����a . J i ; _ . � GI'IMEL ' 1 1 80 East Highway 36 � 2 St. Paul, MN 55109 COUNTRYSIDE 65�-484-844, `T�LKSWAGEN Fax: 651-484-8446 y www.schmelzvw.com ,I Cashiered.Date: 04/10/2014 2:12:36 PM ' �I Illl�u'�I�I�IIIN III SO#: 208255 * ��y�ce Invoice Customer Co �k Auth#: Page 1 Taq#: I�Y F�eet: Customer No: 6990916 Advisor: Shevawn Invoice Date: 04/10/2014 Term: CASH MARY License No Odometer In Odometer Out Delivery Date Stock No MERRILL 101 SO WHEELER ST 719JWD 28203 28205 09/25/2012 920149PC ST PAUL,MN 55105 Year Make Modei Mode)No Color Home:(651)699-0916 Bus: (000)000-0000 2012 VOLKSWAGEN JETTA 2.5L WGN AJ53S1 BLACK Vehicle ID No Selling Dealer SO Date InServ Date Location Cell: (000)000-0000 Today:(651)699-0916 3VWKP7AJ3CM627553 COUNTRYSIDE VOLKS 04/07/2014 09/25/2012 Email:dnh@a.com Fleet# Request/Concern ! Type CSR# Amount i 1 0 CUSTOMER STATES PASSENGER FRONT TIRE WENTI�FLAT AGAIN AFfER HITTING ANOTHER POTHOLE; ' WE REPLACED THE RIM LAST WEEK TIRES WERE REPLACED LAST OCTOBER, RO 200726� MOUNT1 MOUNT AND BALANCE ONE TIRE;SLIT IN SIDEWALL, RIM IS CPVW 426 25.00 BENT. ' MOUNTI MOUNT AND BALANCE ONE TIRE;SLIT IN SIDEWALL, RIM IS CPVW 426 0.00 BENT. 1 281601361 RUBBER VAL C 1.94 1 1T4071498666 WHEEL ', C 276.00 1 DT1696500 PZERO NERO WR03 2 1 K0601173969 CAP C 2•12 Technician 46 DAN i Technician 5 BRAD BUCHANAN ', Cause: verified tire is flat.removed tire from rim inspected found '' bend in outer rim. recomend new rim.tire is ok no signs of damage. no stock on rim jacksonville pdc ' DOT#934U H965 3113 Correction: TIRE PAID BY SONSIO ROAD HAZARD WARRANTY CLAIM#869271 WENT TO INSTALL OLD TIRE ON THE NEW RIM AND FOUND THE OLD TIRE HAD A SLIT IN THE OUTER SiDEVtfALL _ . I REPLACED OLD TIRE WITH A NEW ONE ; MOUNTED AND BALANCED ONE TIRE DOT# ; 934U H�5 3113 ADJUSTED ALL TIRE PRESSURES ; TORQUED LUG BOLTS-89 FT LBS TEST DROVE VEHICLE Thank You Store Hours ' STATEMENT OF DISCLAIMER The factory wavanry constitutes all of the wartanties For Your Business! SERVICE SALES PARTS with respect to the sale of this itemAtems.The Seller , hereby expressly disclaims all warranties either Monday-Thursday Monday-Thursday Monday-Friday express or implied,including any implied warranty Your complete satisfaction is our �.00 am-�:oo m 8:30 am-8:30 �ll 8:00 2m-6:00 p�n of inerchantability orfitness fa a particular purpose. #1 concern.if you can't recommend p P Seller neither assumes nor authorizes any other Friday Friday Saturday person to assume for it any liability in connection our service,or if you have any 7:pp am-6:00 pm 8:30 am-6:00 pm 8:00 am-4:00 pm with me sale of tnis fteml�tems. questions,comments,or if we can Saturday SetU�dey ALL PARTS NEW ORIGINAL EQUIPMENT be of further assistance please 5:00 am-4:00 pm 9:00 am-6:00 pm U-USED O7HERWISR-REBUILT D COf1t8Ct US. � Y-RECYCLED C-RECONDITIONED 3 � v� Dr � � � < �c� om � �n"a �, a � �, o�-a �, �. w � �. � < u� �, -�� � cna �� � Ai� c n� � m • ty O„ w-o c m � .m v m� � � s� r•.> v � � � o � �_. � m m m x � tn � cu n- � '� � ?� � � � a, < � o�wa c �.-o � %�v m m �� Q' � �n � -2.�� � o � Q- Nm v�', o� N N `zm0�• � ¢' � c�'i -°'� � in � �' � � c�nc�o � o � � a � � �'m � OaD ?d � tn� oo � r�.Qw � a =�y � m �'� in�� � �'� o� m � '�� � � sv �� ° ��c�'ic� � s� p ��L ai�' � � �•.�`m� om �;u� o� �� • ��, 5' �� � m � � � � � ? -� �o =.m � ° � m7D0 o D� aw w ai � m o� -�� � � m �, � � �-�ma ? ��� �.� �m �� � N �'D � �D a3 A � �� � �' � Zm= n'�m � °.m � m m s� • °-' �n �, -- �� ti �D � � o � cfl Z �v� n s� ocaa m � io o - a � oa co� � �'� � � � � � � a�iaw � � � � suo �D a� a� � � Q-c� � �°- � -y � � � ° � �o o �n � �co o �m � �D o � � g N � ��� '� � ° o v�i-� �. � iv � � � ° � ci `DC° � � �' �- s � m� � �� D O o� N cn c°'i m c�i' ^> n ° �c° -o � a �.n� � ac7 � � �^ ?m °-� m.� � � � � N•w � N n � `G G�7 �S ¢3 7 n t�/� "� � Q-t�i� cD � (D �- (�D � <D � ..y-. 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SERVICE SALES PARTS with respect to the sale of this item/rtems.The Seller . hereby expressly disclaims all warranties either Your complete satisfaction is our Monday-Thursday Monday-Thursday Monday-Friday express or implied,including any implied wananty 7:00 am-7:00 pm 8:30 am-8:30 pm 8:00 am-6:00 pm Seme r^he i ebias umes or�authonze any ot er #1 concern.If you can't recommend Friday Friday Saturday person to assume for it any liability in connection OUf S2fVIC@,or if you have any 7:00 am-6:00 pm 8:30 am-6:00 pm 8:00 am-4:00 pm with the sale of this itemAtems. questions,comments,or if we can SBtufd2y SfltU�dBy ALL PARTS NEW ORIGINAL EQUIPMENT be of further assistance please 8:00 am-4:00 pm 9:00 am-6:00 pm U US D OTHERWISR-REBUILT D CO�tBCt US. 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Amount � I LABOR 25.00 ; PARTS 280.06 SUPPLIES 2.50 ', SUBTOTAL 307.56 ' SALES TAX 20.13 TOTAL INVOICE 327.69 Recommended/Deferred Services... OP Code Descrintion , DOT#S 934U H965 1313 ' 934U H965 1413 934U H965 1313 934U H965 1313 ' YOUR NEXT IV�AINTENANCE DUE: _ ; -_- _ _�.�__.__�.._ �TO SC}�EDULE, �ALL OP. EMAIL US AT: (651) 484-8441, o� ww�v.schmelzvw.com � THANK YOU FOIR YOUR BUSINESS!! � � ; ; � TIla11IC YOU StOY@ HOUPS STATEMENT OF DISCLAIMER The factory wartanty constitutes all of the warranties For Your Business! 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