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Winesberry i NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the governing 6ody 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 dces not apply,write�N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WE T KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name Middle Initial � Last Name f/V .� � �J� � `` / " RECEIVED Company or Business Name I V 1 � Are You an Insurance Com any? Yes/No If Yes, Claim Number? APR 14 2014 Street Address � lVb � CLERK City �I � � State Zip Code�� Daytime Phone(_) - Cell Phone( �Evening Telephone( ) - Date of AccidenU Injury or Date Discovered S - U � Time ��'S� am/pm Please state, in detail, what occurred(happened),and why you are submitting a claim. Please indicate wh or how you feel �City�of Saint P�ul or 'ts emplo ees,are 'nvolved and/pr responsible for your da ages. �� 5 �, NC6 ; ' '�'D + � e'� � ��}' R- d � L17 ✓ !A� c � /C� , S .{.� � o 'ati U f�% E' r8��% � o�" � � f u r � •t, b UaP�� s ppcA ma� �,,,r� c rts: Please check the box(es)that most closely represent the reason for completing this form: O My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow 6d�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 t�include copies of all apqlicable 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 WII.L NOT be returned and becpme the property of the City. You aze encouraged to keep a copy for yourself before submitting your claim form. C�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 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 comqlete this section Were there witnesses to the incident? Yes No �nk� (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 o park or facilit , closes landm�'k,etc. Please be as detailed as possible. If necess,ary attach a diagram.�lf_ /�'�G �a`f'BCCI{rf� �„ N I�l A If,iUQ f`F,��% f l��,�i� �E�i• `t'� c}i9�1 ��E�' Please indicate the amo nt you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. �j�`A�triOU�i`� � ('nM�ru �nn� f��j� C f��.��J�� f S ��.��I� Vehicle Claims— lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Yeaz Make Model E�'Aluo License Plate Numb r Lf2,� State Color /�/Id�IA� r9A�2 Registered Owner �V S� f Driver of Vehiclg ' Area Damaged tiY�� 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 Q check box if this section does not anplv 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 tp this claim form. Number of additional pages By signing this fornt,you are stating that all inforn�ation you have provided is true and correct to the best of your knowledge. Unsigned forms will not be prdcessed. Submitting a false claim can result in prosecution. Date fo was completed Print the Name of the Person who Completed t ' Fo � � � , �Jr��s �� . Signature of Person Making the Claim: � Revised February 2011 �� McCARTHY AUTO WORLD � � � ' V 3350 129'�Avenue NW � N L O/ COON RAPIDS,MN 55448 =-_ -_ 763-323-3333 =�,- = www.mccarthyautoworld.com CUS70MERN0. �� . AAMES SPATES �� TAGNQr�� '"NO04/07/14 �BUC582�351 �- LABOPRATE LICENSENO. �� MILEAGE . � COLOR S"ff)CKNO. "' KAREN STERLING WINESBERRY 725�R� 12,743 OCHA BRONZ `3448 476 CARROLL AVE Y�R/MAKElMODEL DELIVERVDATE DELIVERYMI�ES ' ST PAUL MN 55103 13/BUICK/VERANO/FWD 1SG 06/29/13 ! VEHICLE I.D.NO. SELLiNC DEALEP N0. �� PR66UG'f10N DATE 1 G 4 P R 5 S K 5 D 4 1 4 6 3 2 4 F T.E.NO. P.O.NO. � � R.O.DATE � � KMWINESBERRY@COMCAST.NET 04/07/14 RESIDENCE PHONE BUSINESS PHONE COMMENTS 651-224-7498 00-36�-s590 x11363 CQSTOEM�t HIT POTHOLE ON LT SIDE ANd TIRE IS NOW FLAT NEED 2 TIRES � REPIACED 2 �TIRES ARTS---=--QTY---FP-NUMBER•--•--------•--DESCRIPTION'....................UNIT PRICE• ' JOB # 1 TOTAL PARTS A.00 JOB # 1 TOTAL LABOR & PARTS 0.00 �� eFm ,_ PERFORM (�1 CERTIFIED SERVICE - CHANCf OIL AND FILTER SCHEDULED MAINT C�tPLETED ARTS•-----QTY---FP-NUMBER---•-----------DESCRIPTION--•-•---------------UNIT PRICE- # 2 1 12605566 FILTER 1.836 6.00 6.00 # 2 5 19293000 5/30 DEXO 8.800 3.83 19.15 JOB # 2 TOTAL PARTS 25.15 ,�B # 2 TOTAL IABOR & PARTS 35.10 NO ALIGN NEEDED RD'TEST AND NO PULLING ARTS------QTY---FP-NUMBER---------•-----DESCRIPTION----------•--•----••UNIT PRICE- JOB # 3 TOTAL PARTS 0.00 Jf)8 # 3 TOTAL EABUR &-fAft�S ,_. -9.�AA-- --------------------------------------------------------------•-----•------------------_-------•- COMPLETE 29 POINT INSPECTION FORM AND REPORT FINDINGS NO CHARGE TO CUSTOMER ----•-----UNIT PRICE- o ARTS------QTY••-FP-NUMBER••-•-----------DESCRIPTION----•--"'� # 4 TOTAL PARTS 0.00 � JOB # 4 TOTAL LABOR & PARTS 0.00 0 � -----•••------- ---------••--------.. x�-�. � ;.; �: . a__ � �MOUNT AND BALANCE TWO FRONT TIRES ; TIRES WORN z MOUNTED AND BALANCED 2 REAR TIRES, PERFORMED COMPUTERIZED � TIRE BALANCE AND SET TIRE PRESSURE. E ARTS-••---QTY---FP-NUMBER--•---------•--DESCRIPTION-•---------•----•-•-UNIT PRICE- g # 5 2 19297276 GY2354518 5.880 N �� # 5 TOTAL PARTS8 199.16 � JOB # 5 TOTAL LABOR 8 PARTS 239.16 _ ---••-------------------•-•-----...-----•-•------••---------••------•-••---••----...----------- � � PAGE 1 OF 2 CUSTOMER COPY [CONTINUED ON NEXT PAGE] 02:30pm SF665901� (01/12) � �� w - 4`s��°�� McCARTHY AUTO WORLD � 3350 129'�Avenue NW n�o� = COON RAPIDS,MN 55448 � � '�� 763-323-3333 �� .^�� '°�� _ � www,mccarthyautoworld.com CUSTOMER NO. � :ADVISOR . TAG NO. INVOICE DATE�� INVOICE NO. � 3332�. AMES SPATES 56 289 04/07/14 BUC582351 � IABORRATE LICENSENO. � MILEAGE ' �CALOR �� STOCKNO. �� KAREN STER�ING WINESBERRY 725�R7 12,743 OCHA BRONZ 3448 476 CARROL L AV E VEAR/MAKE/MODEL ` DELIVEqY DATE ` DELIVERY MiIES ST PAUL MN 55103 3/BUICK/VERANO/FWD 1SG 06/29/13 f VEHICLE I.D:NO.' �� SEI.IING DEALER NO.. PRODUCTION DATE : , 1 G 4 P R 5 S K 5 D 4 1 4 6 3 2 4 F.T.E.NO. � P.O.NO. � R.O.DATE � KMWINESBERRY@COMCAST.NET 04�07�14 RESIDENCE PHONE � . BUSINESS PHONE COMMENTS �� 651-224-7498 00-35�-5690 x11363 ISC------COQE---•--,.DESCRIPTION------------------=------------CONTROL NO----•---- #A SS SHOP SUPPLIES ' 5.00 # 1 NW ENVIRONMENTAL SERVICE FEE 4.00 #`2 HW ENVIRONMENTAL SERVIGE FEE 2.00 0B � 5 W2 4,RiEEI'MI(�i KIT 8.00 TOTAL - MISC 19.00 STIMATE--------------------------------------------------=----°----....---------'--- USTOMER HEREBY ACKNOWLEDGES REGEIVING ORI�INAL ESTIMATE OF' 5309.99 (+TAX? N�IENTS---------------------------•---•--•-------------•-.--•---•--------•--------- IT OTALS--------------•-----------•------------------------------------•-----'----------._...------ LL PARTS NEW OR REMANUFACTURED ORIGINAL EQUIPMENT TOTAL LABOR.... 49.95 NLESS OTHERWISE SPECIFIED. TOTAL:PARTS.._. 224.31 TOTAL SUBLET... 0.00 OR TIME IS CHARGED ON A FLAT RATE BASIS AND MAY BE MORE TOTAL G.O.G.... 0.00' LESS THAN ACTUAL TIME. CHARC�S FOR LABOR TIME ARE TOTAL MISC CHG. 19.00' ERIVED FROM A PUBLISHED FLATE RATE MANUAL OR AN ESTABLISHED TOTAL MISC DISC 0.00 EASO�IABLE AND''CUSTOMARY CHARGE. TOTAL TAX...r.. 16.55 VEN THOUdi Y�1R INSURANCE-OR SERVICE CONTRACT TOTAL INVOICE$ 309.81 �MIPANY MAY REIMBURSE YOU FOR ALL OR PART OF E REPAIR COSTS. IT IS YOUR OBLIGATI�1 TO PAY OR WORIC AUTHORIZED IN THIS REPAIR ORDER. LL GENUINE GM PARTS ARE FULLY fUARANTEED FOR 12 MONTHS OR 2,000 MILES. WHICHEVER OCCURS FIRST. i � 0 U U > Z F Z Q 2 � I V K ¢ � PAGE 2 OF,2 CUSTOMER COPY [ END OF INVOICE ] 02:30pm SF665901 Q (01/12)