Colburn F�EC�IVE�
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APR 2 2 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Min�� n�aCLE�I�
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,ancl
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by ckarly typing or printing your a�swer to each question. If more space is
needed,attach additionai 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 acl�owledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form mnst be signed,and both pages compteted. If something dces 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 w � 1 I f� (.�� Middle Initial ��Last Name �m � ��~�
Company or Business Name " -"
Are You an Insurance Company? Yes No�If Yes,Claim Number?
Street Address ��`�� �6-t-'���"h� �U`"Q—
City "���� 1 State �Y� � Zip Code�� �l�
Daytime Phone�����1 Cell Phone(���Evening Telephone( ) -
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 aul or its e lo ees are involved and/or responsi le for your dama,,ges. �-e.��1
� �- c�cti,-azC� — f 2 � ,Q.c C .�,"_
_ �
��C-�-�t
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 pmperty
O Other type of property damage-please specify
❑ Other type of injury-please specify
In order to process your claim vou need to include copies of all auplicable 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 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
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 handiing of your claim.
All Claims-nlease comnlete this section
Were there wimesses to the incident? Yes No Unknown, (circle) /�
Provide their s,addresses and telephone numbers: �'c �i.r.LV �O (� (�t �-v� -- I .�3 v �r�'v 1-C�
�'�CL1,C C�5'1 � �2,1 C� - G/n S#�
-.k
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 1 dmark,etc. Please be as detailed as possible. If necessary, attach a diagram. �;,�a- � � 'i„a �
�� r' rr, r ��l ek.[.t .r � � ['�V Y —Q--
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. � �� � •C�,� '-'���w"�tLa�
Velucle Clauns- ease com this section �check box if this section does not a 1
Your Vehicle: Year�Make Ct _Model�
License Plate Num�er State/�d�Color�e�(
Registered Owner .��i'((c`A.�.M t� �''�
Driver of Vehicle ''1 �
Area Damaged"G - � � c �-2- c-cJ�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniury Clauns—Ulease complete this sec�on �heck box if this section dces not apply
How were you injured?
What paR(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))
Narne 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 to t'claim form. Number of additional pages�.
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.
Submitting a false claim can result in prosecution. Date form was completed "1 �2'0 '�° t L�
` t,r.h ►�
Print the Name of the Person who Completed ' Form:�it9��l!r�� ,b �6
�
Signature of Person Making the Claim:
Revised February 2011
���� How did �e do? Please, complete the survey at
wxa.atbcares.coa Use password�s�sao�s 0000s
s�RES•S&ivICE•aRAKE�•sl1TVERfEs
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MN NATL TIRE & BAT # 875 * FINAL BILL -INVOICE** Page "1
2185 FORD PKWY Invoice# 75458075 - RI
ST PAUL MN 55116-1816 Order Num 49854263 - WI
(b51) 690-5007 Date/Time In. . . . . . . . 03/05/14 19: 03 :21
Date/Time Promised. . 03/05/14 19:31:20
2d11 HONDA FIT
Tag: 345EUT St: NB+T Mileage: 12525
: Engine: VIN# ��E8H5XBC(7f34927
C`i�s�omer. 2��?1U�3'7 PO#: Ship To:
L�4LBt7Rl�, B���
1.�3#1 -HAR`I'FC}RI�
ST PAIIL MN 55116
Opening Salesperson 12983351 Home# 651-699-1861 Work#
Email• _ _ _ _ _
It�m Numbe� Item Description Qty Price Eac�i Extend�d
IlFf16518�56�i I3ur}Iop BP Sport 7000 Af S 1 �2� .99 �2�.9�:
I3C3T #:II9��t 7�T? �3�2 �
265"�t3���C� �85/55R16 83H,255004140
WORRMANSHIP
Tire aispasal C�iarge Tire l�isposal Charge 3.�t� 3 . �0
PTT `I�C 1NS'�ALL TP 1
NCI� t+�HEEL B�ILANCE NO CHARGE 1
KMTSIt Ni�iINT AND INSTALL 1
12960644 SKARDA, JFsFFREY J.
LTRF LIFETIME TIRE ROTATE SVC 1
MASTERCARI} MasterCard 138.60-
CARD NIIMB�R 3747 APPR 38942P
IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK
__ _ _
TO OUR STORE MAN�GER, WILLIAM PUNCHES
AT f651) 690-50Q7
Special Credit:
Total Charges. . 128 . 99
Total Credits. . . 00
Sub-Total . . . . . . 128 . 99
� New Tire Fees** . 00
Shop Fees (*) • oQ
All Taxes. . . . . . 9 .61
Payments. . . . . . . 138 . 60-
Net An�ount. . . . . . 00
PLEASF PAY ABOVE AMOLT�?T.
THANK YOU! Closer:12983351
I have received the goods and services as represented on this invoice. If this is a credit card
purchase I agree to pay and comply mith the cardholders agreement with the issuer. #This eharge
represents costs and profits to the vehicle repair facility for miscellaneous Shop Supply or
waste Disposal.
Customer Signature
PLEASE SEE REVERSE SIDE FOR WARRANTY,TERMS,CONDTi'ION3 AND OTHER IMPORTANT INFORMATION CUSTOMER COPY