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Pfeiffer
RECEIVED APR 2 2 2014 NOTICE OF CLAIM rORM to the City of Saint Paul, lV�i��es�t�RK �, L Mi,i�tesorn S�ate Stntute 466.05 states thnt " ...eveiy pe�son...wl�u clnims dnnin��es_�rom nny�rrunicipnliry...slrnU cnu.re tn he p�'esenter!to t`�e go��ernir�g 1�ocfy of the�nunicipnliry mithi�t I�SO duys nfter N�e ci!/eged loss or i�yury is discovered a no�ice stating the time,place,and circumstaitces tl�ereof,and the amnunt of contpensadon or other relicf demnnc/ed." Please complete this form in its entirety by clearly typing or�rinting your answer to each question. If more space is needed,attach additional sheets. Please note th.�t 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 f'orm 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'. First Name�1 1��//�t' }�Middle Initial !�Last Nam��N e �k -e h.� _ Company or Business Name ��.� Are You an Insurance Company? Yes/ vo If Yes, Claim Number? �� Street Address ^ �' L � � � , City �v � � '9- State fJ"l/� Zip Code S� �C Daytime Phone (�)��'�Cell Phone (�'�t�2 Evening Telephone (��"�- Date of Accident/Injury or Date Discovered��it.l l l 3 , �v � `f Time ' �v am pm Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you � fe 1 the City of Saint Paul or its em lo e� � e involved and/or responsibJ for your dam•iges. � ,,� ,, �-,Y � _ ' dh-fc� I.�.J ` � Please check the box(es) that most closely represent the reason for completing this form: ❑ Iy1y vehicle was damaged in an accident ❑ My vehicle was damaged during a tow C�/�VIy 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�ou need to include copies 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/ar 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 Fuilure to complete and return both pages will result in delay in the h� - All Claims–please complete this section . Were there witnesses to the incident'? Yes �.� Unknown (c Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes �"� Unknow If yes, what department or agency? Case#or report Where did the accident or injury take place? Provide street address,cross street, intei cl est la dmar etc. Please be as detaile as possible. If necessary, attach a diagra �- Please indicate the amount you are seeking in compensation or what you would like t to your satisfaction. �{�n� ��G Vehicle Claims– lease com lete this se ion ❑ check Your Vehicle: Year�i .� Make Model .L S � `'�� License Plate Number �F(��( �e.e.�P, State��t—: Cr.olor� Registered Owner f?'1 14 x�ti% i�'J.�}/1, c f e i+� P,e� Driver of Vehicle J�J ' ° �e � P�-- Area Damaged 1�-��+ �'w� f i� IL� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) _,.. _ _.. Area Damaged � Iniury Claims–�lease com�lete this section check box if this section doe� not a�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 treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss �vork 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 moc•e pages to this claim form. Number of additional pa�es By signing this form,yor� are stating that ull information you /:ave provided is true and correct to tlie best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date f'orm was completed �' • I �'- / �/ Print the Name of the Person who Completed this Form: E'_ �`�� 'F� t 't�� C..�/ Signature of Person Making the Claim�r' F % Revised Februtvy 201 1 � ; • ,• � p�ACE �� � �'RicK&Ton�'s�F ***** RETI�IL INVOICE ***** ��'T"O�� 04/15/14 1:33pm CASHOI 60475 1 TIRE & SERVICE 1137 South Robert Street 04/12/14 04/15/14 West St.Paul,MN 55118 651-450-0535 651-450-0537 C MAXINE PFEIFFER O1 50963 U Page : 1 - S I Vehicle Information T License : 464-JWB 0 � Make : LEXUS M Phone: 651/249-6641 Model : IS350C E Year : 2012 R Mileage : 11995.0 Hand Ticket: 60475 User ID: KAU � SALES PERSON: 05 xousE SALES PURCHASE ORDER N0: ; . � . . � � � .. � � � NST P225/40R18 BRIDG TURANZA400-02 1.00 280.00 0.00 0.00 280.0� T-TCNC TIRE CHANGE - NO CHARGE 1.00 0.00 0.00 0.00 O.CO T-B COMPUTER SPIN BALANCE 1.00 0.00 0.00 0.00 0.00 T-VS VALVE STEM 1.00 0.00 0.00 0.00 O.GO T-JT TIRE RECYLING FEE 1.00 3.49 0.00 0.00 3 .99 Payment Type: VISA 303.44 , Sub Total 2 8 3 4 9 � Tax Total 19. 3 s AmountDue 303 .�4 HOMEfOWN TIRE 8 SERVICE ACCOUNTS RECEIVABLE CONDRI ONS In the event of default in payment when due of any indebtednes>created TERMS ARE STRICTLY 30 DAYS by acceptance of materials and labor provided by Hometown Tire F.Service, 10% RESTOCKING FEE ON ALL RETURNED ITEMS Hometown Tire&Service shall be entitled to interest on any such'ndebted- ness from the date due at the highest legal rate plus attorney's fees<.nd court NO REFUND ON SPECIAL ORDER PARTS OR TIRES costs,should Hometown Tire&Service choase to employ an attorney:o collect any such indebtedness after default. TERMS NET tOTH PROX.-NIONTHLY � RATE OF t-1/4 SERVICE CHARGE ON PAST DUE ACCOUNTS OR AN ANNUAL • • • • • • PEHCENTAGE OR 18% Customer Signature X - � �, � 1 `g� '. 'l'�$' 2 .'t��'^; � � �. '. . _ k d v�1+' �. ��. �� ��� '���� � 4 i r .�v� =�; � �' �� x,z.. F{ . i 3 .,° d . `��, 7�. ; = �, y* �,'�.-� . , :,`�ka �.� ���'�. � s���� k��� � Yr d;:4"`ctA�i ,� �� ���P� {�`,�« _ t � , Y ' '���. ° �,� � �� ' ° F<;F. �� $���, �r �:,� k° - �� �, 'hr �p,`t.' z _ ��F � ' ` f �Sb �V r ��.�w��s�. vr ♦. • .; �,c , n���„ �����x `.' �~ . s r�+ 4' 'g } fi�r4''...'i ����3''�'�&s�'r, �} �s �� �� ' � .±✓� ""�:� +. 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