Stofflet RECEI\/EC1
APR 16 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
CITY CLEf��.
Minnesota State Statute 466_OS states that "_..eNery person...who claims dmnages from mry municipality...shaU cause to be presented to the
gor�rning J�ody�o�{the mmzicipalir�•Hytlrin 180 a�rrjr after rhe a+dle�+d la.r.r or iRjarry is dircoa�red a notice statinB the ti�ne,place,and
circumstances therieof,ard the canount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your aoswer to each question. If more space is
needed,attach additional sheets. Piease note tLat yon w�i not be conta�ted by t�ephone to darify answers,so provide as
much information as necessary to esplam your dai�and the amonnt of compensation berog reqaested. Yon will receive a
written acl�owledgement once your form is reoeived. T�e proo�ss can take np to teH wceks or bnger depending on the
nature of your daim. This form mnst be signed,and both pages rnmpkted. If somethrog dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST I�LLOC'�G BLVD,310 CITY HALL,SAINT PAUL,MN 55102
First Name 0 N� lvtiddle Initial� Last Name�� ��V r/��—
Company or Business Name
Are You an Insurance Company? Yes/�If Yes,Claim Number?
Street Address T�� � �� � � � L T
City 'I'f���� State 1�, v Zip Code��J
Daytime Phone(�� zfZ-�Cell Phoue(_) - Evening Telephone(_) -
Date of Accidend Injury or Date Discovered 2-�� Time ✓ `�3 � am�
Please state,in detail,what occurred(hap�ened),and why you are submitting a claim.Please indicate why or how you
fe 1 the City of Saint Paul or its employees are involved and/or responsible far your damages. 1�✓,�v 2 s o�2.
,� �� � (..s�� � � ...*� �R-� ar S a u-rl.. .T L L,e�o v�.�
v �cs�.-. � �r-:�.P., S�E- � o �rf-' o-,-. �'�
. �. �� , 1��t- r�'i- �'-c,4-r� -�,`.�t �' L►�,..P �{o
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Yo k � :r�s w-.� .ar,�.? 1 � s�►m� a,-. T� � Y � e� �
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G,S W t,,,rY �-r.( w o.v��� ) '�-e � w.�� 1i'-�c�`r�S GC.�c:✓I,P�
Please check the box(�e,$)�t most closely represern the reason for completing this form:
❑ My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
�My vehicIe was damaged by a pothoie or condition of�e strcet Q My vehicie 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�ou need to indude oouies of all anulicable docaments.
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 become the property of the City. You aze 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�amage exceeds
$500.00;or the actual bills and/or receipts for die repairs
O Towing claims:legible copies of any ticket issued and a copy of the impound lot receipt
O Other groperty damage claims:two regair 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
C� Phntc���^hs�P a�v�rays wel�!??e±e�cu.*�*.�i.a.*x��Ll�1Q�Ji��4l���ai�}�iit�lL�130t�LQ�1I!??�.
Page 1 of 2-Ple�e complete and retnrn both pages of Claim Form
Fa�ure to complete snd retera bot6 page.s w71 resott in delay ia t6e handiing ot your ciaim.
All Claims—ulease comnlete this section
Were there w2i�esses to the�n�deat? Yes � Uuknvwn (c�rc�e}
Provide their names, acldresses and telephone numbers:
Were the police or law enforcemern called? Yes � Unknown (circle)
If yes, what deparnnent or agency? Case#or report#
Where did tl�e accident or in1�ry take p�aee? Provtrr�ee straei ad�dress,cr�s sireet,�ntersee�io�,name of gark or faei�2ty�,
closest landmazk,etc. Please be as detailed as possible. If ,attach a dia am.
� .r.d�: W /L o�►-• -✓' r
Please indicate the amount yau are seeking in com�pensation or what you would like the City to do to resolve this claim
to your satisfaction. �'L e- � � ��r� � ' � r'^�- �.�'�-,
W���1 �p
Vehicle Claims— lease co lete this ❑check box if this section dces not a 1
Your Vetude: Year 2�l'�— Make Mo�t �n
License Plate Number State i��/Coi� �e
Registered Owner ��;�NF- r �F�T
Driver of Vehicle � _ �—�—T
Area Damaged •�,� � f�— N••� ' ��v�
e�ty���r�et�: ��� �r�� ; ���
License Plate Number State Color
Driver of Vehicle(City E�loyee's Name)
Area Damaged
In,�urv Claims—ulease comvlete this section �check box if tlris section does not atrolv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatrnent? 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 resuit of your injury? Yes No
When did you miss work? {provide date(s))
Name of your Employer:
Address Telephone
❑ Check here d yon are attaching more p�es to tLis da�form. Nnmber uf�lditional pages
By signing this form,you are stating that all infortn�ion you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be prbeessed.
Submithng a false claim can result in prosecution. Date form was completed < �' �l�
Print the Name of the Person who Completei ' Form: ��.�N�� S���G��-/�
Signatnre of Person Making the Claim:
Revised Febn►ary 2011
� �
luthe FIAT 1820 QUENTIN AVENUE
�'"'� ST. LOUIS PARK, MN 55416
Minneapolis www.fiatminneapolis.com
PH: 952-367-4400
Bloomington • St. Louis Park FX: 952-367-4401
. ,
CELL: 651-252-1763
��STO��ERNO ��N 523 �A�"°450 '"��q��l/14 �'��5334
ODNEY STOFFLET �BORR^TE ���€xC ^^���GE 17',4gg �'/ sT°`""°
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908 TWINS CT �q� DR HB SPORT oeu�.�eRVOaaF oe_r�-ER���+i�es -
AGAN, MN 55123
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RESIDENCEPHONE BUSINESSPHONE E-MAILADDRESS MO. 1/47S
....."""""'"""""""""" "" ' ' ' . . .. . . . . . . . .
THANK YOU FOR THIS OPPORTUNITY
-•----------------------------•-_------'--•_---------_---_----•---•-----•------ TO SERVEYOU.IT'1S OUR AIM TO P=R-
, _ FORM ALL THE REPAIRS REQUES�ED
CTS: The customer fiit a pot 'hole. ON THIS REPAIR ORDER TO YOJR
LEFT FRONT AND LEFT REAR TIRES DAMAGED. BULC� IN BOTH TIRES connP�ETE saTisFACriorv. iF c�R
LEFT REAR HAS HOLE IN SIDEWALL. NOT REPAIRABLE. SERVICE WAS SAT�SACTORV TE��
RECOMMEND REPLACIN� TWO TIRES AND PERFORMING ALI6NMENT
CHECK YOUR FRIENDS. IF NOT, PLEASE Ti LL
MOUNTED AND BALANGED TWO'TIRES. ROTATED RICHT FROI�T US IMMED�ATELY. '
TIRE TO lEFT REAR. PERFORMED ROAD FORCE BAIANCE. MO
DAMACf DONE TO WHEELS. BALANCE WITHIN SPECIFICATION.
TS------QTY`--FP-NUMBER---------------DESCRIPTION-------•------•-----UNIT PRICE-
2 1548828 ` TIRE 145.46 290.92
TOTAL - PARTS 290.92
1;TOTALS--•------------------•------------.--------••---•-•-•-------
LABOR 42.36
' �PARTS 290.92
JOB# 1 ,�URNAL PREFIX '�FICS JUB� 1 TOTAL 333.28 ChedulE'
. 2�.CH�C7ES' . """�•".S""""""'-.....- ""--"'.'--._..'"-.""'--'--"'.- . On�lineseiviceschedulingatLutherAuto:co..
� CUSTOMER REQUESTS WHEEL ALIGNMENT CHECK.
HIT POT NOLE.
` REAR TOE ALIGNMENT AND FRONT TOE ALIGNMENT OUT OF
MANUFACTURERS SPECIFIGATION. REGOt�IEND 4 WHEEL ALIGNMENT
PERFORMED 4 WHEEL ALIfNMENT. CLEARED STEERING PULL
COMPENSATION. VERIFIED OPERATION.
2 TOTALS----------------•-•-----'--....-•--------••••---••-''. LABOR 127.50 THANK Y�V�
WE APPECIATE YOUR BUSINESS "
J�# 2 .lOURNAL PREFIX` FIGS JOB# 2 TOTAL 127.50
3 CHARGES---•-------------•--....---------..._.....-------------------•--••------------•-'
� CUSTOMER STATES INTERITTENT GRANK NO START CONDITION.
CHECK AND ADVISE.
SOFTWARE"UPDATE
UPDATED ENGINE CONTROL MODULE SOFTWARE. "Any warranties on the products sold hereby�re
those made by the manufacturer.The se er
�' 3 TOTALS---------•----------------------------•-`-•-'-------•----"•- (abovenameddealership)herebyexpressry,lis-
claims ali warranties,either express or impli�d,
g JOB� 3 JOURNAL PREFIX FIC$ JOB# 3 TOTAL 0.00 including any implied warranty ot merchantab�ity
�I SC--- ' -CODE--•-----DESCRIPTION--_-----`----DISPOSAL------•---CONTROL'NO•=--=---- 3.50 ass'umetorotraPthob�ity aco�nectioewtn �er
N __ iO
rJ B # A EOD ENVIRONMENTAL HAZARDOU$ ne
� # A SS SHOP SUPPLIES 16.� sale of said products."
�, . TOTAL - MISC 20.49
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o AGE 1 OF 2 CUSTOMER COPY [CONTINUED ON NEXT PAGE]` 01:49pm
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� �the FIAT 1820 QUENTIN AVENUE
�'""'� ST. LOUIS PARK, MN 55416
Minneapolis www.fiatminneapolis.com
PH: 952-367-4400
Bloomington • St. Louis Park FX: 952-367-4401
CE��: 651-252—:1763
��s��MER�� �EN 523 TA�"°450 �'"��9��1/14 ��05334
ODNEY STOFFLET `'"'BO�RATE ��i�xC "^����E 17,4gg �/ STa�K"o.
908 TWINS CT �+ ��� � O 2DR HB SPORT °E"`ERYO``-F °E`'�ERY"�'�E'
AGAN, MN 55123
H��E� N� F F B R 5 C T 3 8 5 4 4 7 5E �N�orA�FR No ,PROO����oN oA�E
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od.stoffl et@yahoo.com F�� N� P� �� R�� 11 14 �
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F[SIDcNCEPHO��E BUSINESSPHONE E-MAILADDRESS � MO: 17�t95
---•---......- - -- - -
STOMER HEREBY ACKNOWLEDGES RECEIVING THANK YOU FOR THIS OPPORTU'�ITY
ORIGINAL ESTIMATE OF 5550'.00 (+TAX) TO SERVE YoU.IT tS OUR AIM TO 'ER-
MMENTS-----------------------=-•`----.._.......--------------------•-'---•-•-------• FORM ALLTHE REPAIRS REQUE�TED
reated 2014•04•11 07:46:OOam taken by jaysen cook ON THIS REPAIR ORDER TO Y �UR
TAL$-.....----•-----------------------------••-•...-•--------.__._.........-•-•--------••--•-- COMPLETE SATISFACTION. IF �UR
SERVICE WAS SATISACTORY -'ELL
************************************************* TOTAL LABOR.:.. 169.86 YOUR FRIENDS. IF NOT, PLEASE ,^ELL
* TOTAL PARTS.,.. 290.92 US IMMEDIATELY
* TOTAL SUBLET... 0.00
GASH [ ] CHARGE [ . ] * � TOTAL G.O.G.... 0.00
* TOTAL MISC CHG. 20.49
* TOTAL MISC DISC ' 0.00
CHECK`C ] ` CHEGK'# C ] * TOTAL TAX...... 21,17
* --....._
* TOTAL INVOICE$ 502.44
= AMEX C ] : DISCOVER [ ] *
*
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VISA/MASTERCARD [' ] * ' ChedU��i
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�� �� - � � � - �� . . . .. , . . On-line servire schedulingat Lu�herAu ,com
THANK YOU!
WE APPECIATE YOUR BUSINFSS
I
"Any warranties on the products sold h;reby are
those made by the manufacturer.T°e seiler
(above named dealership)hereby expr ssly dis-
claims all warranties,either,express o implied,
o ' including any implied warranty of inerc'antability
e or fitness for a particular purpose,ar J neither
� ; assumes nor authorizes any other�erson to
N assume for it any iiability in connectic�with the
� ' saleofsaidproducts."
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