Capocasa RECEI�I�D
APR 15 2014
�� NOTIC� OF CLAIM TORM to the City of Saint Paul, Mi���p�E��
Minnesotn State Stutute 466.05 stntes that " ...everv persun...whu c•lnims dmm�ges.frmm�n��municipnlih�....rl�nll cnu.se tn he pre.�•entcd to the
��nverning/�ucly oJ'the municipn/ity withi�t /�SO dn}�s nfier(he o//eged/oss or injurv is cliscovered a notice stotiirg the time,p/ac•e.�arcl
circuntstunces tlrereo/;and tlie crmotuu of compe�rsaJinn or other relief demm�ded."
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 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 reryuested. 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 DOCUM�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, S,�INT PAUL, MN 55102
r/ � � ��,
First Name � Middle Initial Last Name
Company or Business Name � E /e �%
Are You an Insurance Company? Yes/ 10 If Yes, Claim Number?�/ �f ri' /" �
Street Address � � ����
City �� / T�U � State ����!/`� /� ' Zip C e �J � � G�
�� _ �� �� ( - Evenin Tele hone ��� !. � v �� �
Daytime Phone (���� hone ) g p �
� �a
Date of Accident/Injury or Date Discovered � ° ��� ` ' 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.�re involved and/or re.� sible f r yo}�r d• ages.
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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 d�uing 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 anci/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 applieable 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 returne� 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 propercy damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repnirs; 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 comn�ete this section
Were there witnesses to the incident? Yes � 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, intersecti�r�pme pf�rG or��cility,
clo�est landmark, etc. Pleas�,be as detailed �is ossible. If necessary, attach a iagram t�°6����''ti �s
�' ." ' '� �/� G
Please indicate the ar�g�Tn�you�re se�k� in compensation or what you would like the City to do to resolve this claim
�
to your satisfaction.,�5 �D � 1�
Vehicle Claims— lease com lete this section ❑ c eck box if this sectiWn does not a 1
Your Vehicle: Year_,��D_Make - Model
License Plate Numb � ' - " �State olgr d ��
Registered Owner ' � � ��
Driver of Vehicl '�'
Area Damaged
City Vehicle: Year Make /�/� h.!� Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injurv Claims—please complete this section �check box if this section does not ��plv
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 treat►nent? �' -v (provide date(s))
Name of Medical Provider(s): O/uL�
Address elephone
Dicl you miss work as a result of your injur '� Ye�
1JVhen dil�nu mi�� wQrk2 --- -- � L E�t3� ------ ___ _ _�pr, ; �ate�s)�
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
I3y signing tliis form,you are stating tlzat ull information you /aave provided is true and correet to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can resiclt in prosecution. Date f'orm was completed "/ /�y ` y
Print the Name of the Person who Completed this Form: "/3 �• l,� /� O G' '� ��
Signature of Person Making the Claim: �
� ��
Revised February 201 I
. 1�"".�"'7' 'C�GG�d
CUSTOMER #: �E2s4. 418042 WHITE BEAR
*Ir�voICE* LINCOLN
GARY ALBERT CAPOCASA
1519 REANEY AVENUE INC.
S T PAUL, MN 5 510 6 PAGE 2 3q25 N. HIGHWAY 61 • ST.PAUL,MINNESOTA 55110
HOME:651-771-9900 CONT:651-771-9900 (6511483-2631
BUS CELL SERVICE ADVISOR: 1 STEVE MOGA
COEQR l! AR �l lMQQ ? #.I S� ; M1LE ENl;O TAG ;
GOLD 00 MERCURY GR.AND MAR UI 2MEFM74WOYX654840 FEA614 35404 35404 3798
�FL DAT'E PR�[3.:I�ATE ;V1tARA EXP PR�1�kES�i7 PE�;hi�, :'R�TE > PA�'A�I�NT;:: <:IINV.RAT�
02MAY00 D WAIT 09APR14 131 _ 00 CASH 09APR14
R.q;flP�hiE�3 ' R�A�Y" ' OPTIOtvS: STK:P12912A DLR:64A497
ENG:4 .6 Liter EFI SOHC (R) 1) ESP NEW EXTRACARE
08 : 38 09APR14 11:55 09APR14 84 60 2 EXPIRES 9-4-07 OR 60 000 MILES More. . .
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
354 t�4 COMPLETEID �LT�AI�4��-�RY f�I:TNDY':?'Oi�JTSTDE BUT FEE� GC3QF� ;
*********************************************�******
SHaP eH�R.GE _ _ _ _ < 3 5.:(7 0
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_ _ 37.17
ANV WANPANTIES ON THE PRODUCtS SOLD ;��s`��'tP'j'�� ;QT�I�
HEflEBV ANE THOSE OF TME MANUFACNnERS. �--�� ����� � 'J o']
•S BET4EEN TMI$RETA�L SELLER AND&1VER, LABOR AMOUNT „J O S . O J
THE PROOULT IS TO BE SOLO'�5 IS'AND TIE
� ENTIPE PISK FS TO THE �UALITV AND p
PERFORMFNCE OF TNE P1100UCT IS WITM TNE pARTS AMOUNT S 2 1.�p
gUYEp. THE SELLER EXPRESSLV MSCUIMS ALL
L I N C O L N W�RRIIMTIES, EITNEP EX%1E55 ON iMrueo, GAS�OIL,LUBE O . O O
INCLU�ING PNV IMPLIED W�RRANTV OF
MEpGNANTFBILITV OR FITNE55 FOR A
YARTCULAR %1FPOSE, AND T1E SELLER SUBLET AMOUNT O . O O
NEITHER ASSUMES NOP Al1lMOR12E5 ANV
OTHEP PERSON TO ASSUME fOR IT RNY 3 5 . 0 0
�'�/� / �� LIRBILITY IN CONNECTON WITN THE SALE OF MISC.CHARGES
t-�� SAID PNODUCTS. TNB UISCLAIMEP BV THIS
I/�O
`` 'YtI�IY SELLER IN NO WAV AFFECTS TNE TERMS OF THE TOTAL CHARGES 8 6 5 . 51
C�L/ MANUFPCTUREF'S WARRANTV. iHE BUYEP
� pCKNOWLEDGES BEING 50 INiOPMED Pf110R TO LESS INSURANCE O . O O
'�� ��•' THE SALE.
ALL PARTS NEW ONIGINFL E�UIFMENT UNLE55 �7
OTNEPWISESPECIFIED. SALES TAX 3 / . 1'J
CUSTOMER SIGNATURE pLEASE PAY
THIS AMOUNT ; 9Q2.&$
CUSTOMER
• �7� ��d
CUSTOMER #: f3E'254, � 418042 WHITE BEAR
� *Ir�vol�E* LINCOLN
GARY ALBERT CAPOCASA
1519 REANEY AVENUE INC.
ST PAUL, MN 55106 PAGE 1 $4y5 N.HIGHWAY 61 • ST.PAUL,MINNESOTA 55110
HOME: 651-771-9900 CONT:651-771-9900 (651)483-2631
BUS CELL SERVICE ADVISOR: 1 STEVE MOGA
' 4L0€i l'EA ' K fMD L VIM11: < �IC NES� 1L �EN/'O TAG `
GOLD 00 MERCURY GRAND MAR UI 2MEFM74WOYX654840 FEA614 35404 35404 3798
[3fL�?A`fE PR�p i)ATE iIVAR�f £)tP PE��pMtSEi) :; . RO REt). `:R�4TE : RJ�YldIEGJT' IidV.QA�E
02MAY00 D WAIT 09APR14 131. 00 CASH 09APR14
p,f7;;{)p���#} !;;Rg�#?l'::; OPTIONS: STK:P12912A DLR:64A497
_. _ ,.
ENG:4 . 6 Liter EFI SOHC (R) 1) ESP NEW EXTRACARE
08 :38 09APR14 11:55 09APR14 84 60 2 EXPIRES 9-4-07 OR 60 000 MILES More. . .
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
A 1�F�'EI2 HTTTIN� P,. POT HC'3L� THE VEHTCLE �I$RATES AND: HP.�S ;;A SL:IGHT , PULL, _
___ _ __ _
LEFT
313OA."TIE R0� END ANE7 jE3R DRi�G LS1�#K �- R�pL�i,C�
(3A130/3A131/3304) - L
�s�� cr:,� _; ��.� .;9� ai�.�3
1 2W7Z*3A130*A END - SPINDLE ROD CONNECTING 71. 92 71. 92 71. 92
1 `2in1?�*3A�,3�,'�A.k�A -` SP���� �t�� C41t7I�E��`z1�I� > 7�, aQ 7(1.;00 70.0�
1 F7AZ*3310*AA SLEEVE 73 . 86 73 . 86 73 . 86
F�RTS:' �I5.`78 Ii�BQR:;` 2�.2 93 O�HER:; 0 .O il 'I`dTAL �,II�TE A: ' 4 2 8 :71
35404 FOUND FROZEN TIE ROD ENDS-REPLACED LEFT INNER AND OUTER TIE
�dD END� ; ` _ _ , I ' _
<
****************************************************
B QU���LP,1�E 5D `:P�7�NT �1�iSPEC'I`IfjN >
Q99P QUICKLANE 50 POINT INSPECTION
�s�� ��az, : �N���
GTIRE CHECKED TIRES NORMAL WEAR
3��3 IP.:aL ` �I�T/'C)
GBK BR.AKES NORMAL 5MM DISC OVER 2MM
` 382?3 �PO� �T�f:C7
, ,
PARTS: 0 . 00 LABOR: 0 00 OTHER: 0 . 00 TOTAL LINE B: 0. 00
�54 b4` �CaP?�I��E�D �NS�'EC"���N '; ; _ , >
****************************************************
C** MbtlN'Y' � BAL�NCE � �'�:12E� !>
15M2 MOUNT & BALANCE 2 TIRES
':: 3$�3 C�LT �5,'95 i 35. 95
2 9004*98499* P225/6OR16 BK 166 . 95 152 . 95 305. 90
PA�.TS i 3 E}5,�Q I�ABL'��:: ; 3� .9 5 4THER.: 0.il{3 �'t3TAI� LTNE �. ; : 3 41:8 5
_ ..____.. .__
35404 MOUNT AND BALANCED 2 TIRES NEW DOT M33V F6FX 1214 FOR 1 AND
1�33V !�'C�'� 01.14 �'bR 1 , ,' ' ? ' !:
****************************************************
II** 2 :WH��,'L Ai,�GNMEk�TT
14B2 2 WHEEL ALIGNMENT
' 3$23 CQLL ' : ' ' 59s9� �9: 9�
PARTS : 0 . 00 LABOR: 59 . 95 OTHER: 0 . 00 TOTAL LINE D: 59. 95
ANV WARP�NTIES ON TIE PNOOUCT$ so�o .:,(]ESCREPT�ION TOT�YLS
XEPEBV APE THOSE OF TNE MANUFACNRERS. ����� ���-�-������ "�'-'
�5 BETNEEN THIS RETAIL SELIER ANO&1VEF. LABOR AMOUNT
TIE PRODUCT IS TO BE SOLO'F$IS'AND TIE
� ENTIRE PISK AS TO THE �UALITY �ND —
rERWHIMNCE OF THE PRODUCT IS WITH THE pARTS AMOUNT
L I N C O L N ��q' THE SELLER EXPRFSSLV DISClA1M5 ALL
INCLUDINGES,�NYTMEIMP�EUESWAflRANTV IOi GAS.OIL� LUBE
MERCN�N�Adl17V OR flTNE55 FON A
PARTLULAR WRPOSE, ANO THE SELLEF SUBLET AMOUNT
NEITHEP ASSUME$ NON AU7HORI2E5 RNV
OTMER PERSON TO ASSUME FOR IT ANV
�'�,I � �� LIABILIT'IN CONNECTON WITI iNE SALE�F MISC.CHARGES
���� SPID PPODUCIS. iM15 DISCUIMEfl BV T1ii5
`//IIO
�A���r SELLER IN NO WAV�FFECTS 7HE TERMS OF TIE TOTAL CHARGES
MANUFAC7UPER'S WARRANT'. TIE BUYEH
� �'��A��' ACKNOWIEDGES BEING 50 INFOFMEO PPIOR TO LESS INSURANCE
!_�—_-` THESALE.
riniii� I1LL V�FTS NEW OFIGINAL EQUIPMENT UNLESS
zr�'•• ornenwisesreciFleo. SALES TAX
►
CUSTOMER SIGNATURE pLEASE PAY �
THIS AMOUNT
CUSTOMER
VEHICI�E REPORT CARD LEGEND
L I N C O L N nt May comribute to veoicle ellicien�y
.� � � . � : •-• • •• • • and promote a greener environmerrt
L.� S E R V I C E �Checked and OK at this tlme
Date: 1 �� ( m RO/Tag#: � �
�May roqWro lulure atlentlan
Name: � � + �Nequiros Immedhts sttentlon
Email: �� `� �
Year/Make/ModeL• QU �"��-
y�N�; Plate#: Note any
c' existing exterior
Odometer. 3 S T° y Inspect.Month: � body damage
or defects on
OwnerAdvantage Rewards�#: Service Balance: diagram
Lincoln Extended Service Plan: ❑ YES ❑ NO
SYNC°VHR Activation: ❑ YES ❑ NO ❑ N/A � ��
. . somceo
' � ' ■ Operation of horn,interior lights,exterior lamps,tum signals, �
� � �E �D hazard and brake lamps
�The Works � �Engine Air Fifter �J �
. Windshield for cracks,chips and pitting �I
Q Oil Change&Filter �1 � �Engine Coolant �
• • SERVICED
0 Tire Rotation �J � �Transmission Fluid&/or Filter � HVAC system and hoses/lines for leaks andlor damage �
0 Multi-Point Inspection � �Cabin Air Fifter � � �,
�Fuel Fitter � �Spark Plugs f�J � Engine Cooling System,radiator,hoses and clamps
� K Scheduled Maintenance � Accessory drive belt(s) C'
"fhis is only a partial dat of vehick maintenance items and is NOT all-it�cWsive.Pbase conwR your - ���
Owner's Manual or risit UncolnOwner.com for vehiGe-specific maiMenance require�. ❑
� �n� Brake system(including lines,hoses,and parking brake) �C7
Oil and/or fluid leaks �jv�y�,v r` ���%' ❑ � � � ���
mc Ru Ru FlLL Shocks/struts and other suspension components for leaks ❑
�Engine Oil ` �Power Steering �rf�nsmission and/or damage
(equipped wiTh dipstick) ❑
�Brake Reservoir �Window Washer �Coolant Recovery Reservoir Steeting,steering linkages and ball joints(visuaq
sExnceo
� . sexncm ❑
❑ Exhaust system and heat shield(leaks,damage,loose parts) p
� Wiper Test Pertormed Wiper Blades
. . - sEmnceo
sexv�o . .
State oi Health s Battery Condition � Clutch operation(if equipped) �
- 00% � Constant velocity(CV)drive axle boots(if equippe� �
�� Drive shaft,transmission,u-joint and shift linkage(if equipped)
Factory spec cold cranking amps Actual cold cranking amps and lubricate(as needed) �
� y�"��"
� � � � �� �falf�talA�R'b7p�C"�II!)+DRL�!'kl�lt�tw$�it�{:�t`198�"; • i
. . � -. jfJ serv� • •• S7 sExv�o
.` ignment check needed � Tire Tread Depth /32" �Tire Age J � Tire 7read Depfh /32"�Tire Age �
�Wheel balance needed � Tire Wear Pattern!Damage ` � _ Tire Wear Pattem/Damage �
Tire Pressure set to tactory-recommended PSI � � Tire Pressure set to iactary-recommended PSI �
Bt�ce me85luetneMS not � &ake Lining mm _J32" � Bralce Llning mm /32" ❑
tllis�visit
- p SERVICED ' � SfAY10ED
�-�----...._..--_. :—._..--�-----.
• Tire Tread Depth /32" 'Tire Age � Tire Tread Depth /32' Tire Age , �
--- _ _ _____
�Complimentary car wash
Ti�e Wear Pattern/Damage ❑ Tire Wear Pattern/Damage ❑
COmm2(lts: Tire Pressure set to factory-recommended PSI � Tire Pressure set to tactory-recommended PSI �
�N��l`�C �-�t/�{�s ���„i'
f� Brake Lining mm /32" � &ake Lining mm /32" �
�w v5� �n�. �4.'�-T� �
SERVICED
Lf�r��lst R� 4��5 ��-► rre�„re set Tire Age � �J LincolnOwner.eom
� !N One site for all your vehicle needs
Advisor: ��.J� Technician: ���� _
Customer Signature: _
Dealer eStore Item#VRGLINCOLN,Rev.07/12
" � LINCOLN
.
" „ SERVICE �
�
TOE WEAR CAMBER WEAR
"Feathered"tread wear pattern Exaggerated wear on inner or
suggests that tires are turnetl outer edge of tire indicates that
in or out too far.Signals need tires are tilted in or out too far
for atignment.May be caused (from vertical).Signals need for
by worn shocks/struts. alignment.May be caused by
worn shocks/struts.
- � � �- . �y I+ -I
� o
TOE-IN TOE-OUT POSITIVE NEGATIVE
CAMBER CAMBER
DISC BRAKE DRUM BRAKE
NUB STATOR
RING
BACKING
J P�
CONNECTING
O SPHINOS
� ° po� O
O � o � O
ABSSENSOR �� �
0
BRAKE CAUPER BHAKE DRUM
� BMKE PADS ? �
BMKE DISC(ROTOR) , B�� �
SHOE ��/
WHEEL v � Q
CYLINDER � O�
AWUS� �
t.ENER
ADJU871NCi STMWHEEL
� �K ADJUSTER
SUSPENSION
INNER TIE ROD UPPER CONTROL ARAA �
_� �BALL JOIlIT '
OVfER TE ROD •
�.�/ �` / STF1Ui-TYPE COIL SPRING e I
\SUSPENSION ��K�l
I ABSORBEFi �
� l\ / � 1 �
�- � � \ �/ �# WHEEL HUB
V � � /
�f�r== � /�EELBEARINGS
� �,�T STEERING WHEEL
� �OUTER T1E ROD
�� '�►/
�' LOWER CONTROL AflM
STEERING GEAR ` _ '
�•I
INNER TE ROD