Patterson -. RECEIVED
APR 18 2014
CITY CLERK
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota Stute Statute 466.05 atates t/tut "...every person...who cluims dumuges from any municipaliry...shull cuuse to be presented to the
governing body uf the municipulity within 180 duys ufter the ulleged loss or injury is discovered u notice stating the time,place,arul
crrcumstaizces thereof,and the u�nou»t of coinpe�zsution ar 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 does not apply,write`N/A'.
SEND COMPLETED FORM AND O'P,I�R DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL SAINT PAUL, MN 55102
First Name Middle Initial�Last Name �-�-�^2r��nl�l
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address ��1_L'41 �(��1'1��'�' f�Q N�2 U1,111T�
City W� „ U f"t/ State� � Zip Code J�c�
Daytime Phone( ) - Cell Phone((�,�j)�'-��Evening Telephone((o�)�-��
n •
Date of Accidend Injury or Date Discovered�,G� �'<j�6��Time • �/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 are involved agd/-or responsib e for your dama s. Z
r��� `f11
h /M.
.Q. �
l ��
� C- �I� l
� � ¢ l�{ �fi�
� � I'NCa+�r��'�'.
Please check the box(es)that most closely represent the 1-eason for completing this form:
❑�ty 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 O 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 to include copies of all anplicable 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 propefty of the City. You are encouraged to keep a �
copy for�yo�self before submitting your claim form.
'O'Property damage claims to a vehicle: two eskimates 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-qlease comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or]aw 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,
�cl est landmark,et� Please be as detailed as possib e. If necessary, attach a diagram. ��h��_8-�./"'
—C76� C.—�iGL CJ"D SSE �i�P
Please indicate the amou you are eking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � � ��. �a..
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make - odel
License Plate Nwn State��Color
Registered Owner .
Driver of Vehicle
.Area Damaged
City Vehicle: Year M e Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-please complete this section �'check box if this section does not applv
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 to this claim form. Number of additional pages
By signing this for�n,you are stating that all informatiorx 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 �� —�
Print the Name of the Person who Com d this Form:
Signature of Person Making the Claim: �--
Revised February 201 1
Customer Invoice FIRESTONE COMPLETE AUTO CARE Service Advisor:
116703 SUNRAY 01 CLINT
03/26/2014 2041 OLD HUDSON RD 651.739.3423
SAINT PAUL, MN. 55119-4403
Re-Printedon 04/17/201410:45AM DUPLICATE INVOICE
2007 MERCEDES-BENZ S550 4MATIC [BLACK]
PATTERSON, RUNNEY V8-5461 5.5L DOHC
10741 FALLING WATER LN Lic#: VGZ523 MN Vin#: WDDNG86X57A091958
SAINT PAUL, MN 55129-5331 In: 03/26/14 10:51AM Mileage: 76,657
651.769.4687 xRUN Out: 03/26/14 11:52AM
Store#020338 RETAIL SALE
Rev Hist Unit Extended Job
Description /Article# ID Qty Price Price Total
WHEELS - - - 01 . 629.99
CUSTOM 19"22 SPOKE SILVER WHEEL 7019852 25TN 1 629.99 629.99
FLAT REPAIR 8�BALANCE 50 SERIES AND BELOW W/TPMS 01
(Spare)
� 1040K TPM�-�#�'6-2�6�--�----- h 7008220 25TN 1 15.99 15.99
PRT-DISC DISCOUNT TPMS KIT 6-206 7001665 25TN -1 15.99 -15.99
TPMS VALVE SERVICE KIT LABOR 7008190 25NS 1 2.99 2.99
LBR-DISC DiSCOUNT TPMS VALVE SERVICE KIT 7001665 25NN -1 2.99 -2.99
LABOR
LP FLAT REPAIR LABOR 7008211 25NS 1 20.00 20.00
LBR-DISC DISCOUNT LP FLAT REPAIR LABOR 7001665 25NN -1 20.00 -20.00
INSPECTION
FROM PRIOR INSPECTION
Technician(s):
25 RIA VANG
Payment History: Summary:
CFNA 2055 678.02 09760 Parts 629.99
Total Tendered 678.02 Labor 0.00
Shop Supplies 0.00
- - - - - - - - Sub-Total 629.99
All.CFNA purchase(s)through December 31, 2014 of$299 or more Tax(7.625%) 48.03
receive 6 month deferred interest, see www.CFNA.com for more details.
- - - - - Total $678 02
I have received the above goods and/or services. If this is a�redit
card purchase, I agree to pay and comply with my cardholder
agreement with the issuer.
Customer Signature
All parts are new unless otherwise specified.
TELL US ABOUT YOUR EXPERIENCE TODAY AND ENTER DRAWING FOR$5001N SERVICE!
Call 1-800-859-9203 or go to www.FirestoneSurvey.com; Enter code 020338-116703
Offer expires 10 days from date of invoice. Good at all participating locations.
- www.FirestoneComp�eteAutoCare.com
�� � � �� . � . �� STD FCAC LASER 7008335-481103'3 fi-.V 1 1.1 �� �
Page 1 of 1
. {r �R', r., . , _.,.:'iJ I 'i�:,,..,,-.� Inv1 13073' 402114
�,ee revF� �� ; cie ��r w.a��ai ��� ,
�li�ll7"�� iN�►Ti�NiIViED� S�R�d'ICE 161I��I�AI�ITY
`��s�� g��.����:�: ��B.��i��c��arsr� a� as�s��c�rti�rm� xes u�:
��ar�� ��c� ��� ya�;� ;a�a�������e.,A: ��restone Gomplete Auto Care, c,ur goal is complete customer satisfaction. If ycu rr��r ��.% �: . . ,
rr c�ncer�"5 r �,a�a�r� , � _� � ,���a y�u recci��.�ed o; our nationv�i�e !�miied v✓ar��:�i1� ������ emnt�c��9�e IV���6� �r of the �� �
f;cni of ths���o.u��ert ���i �iay also contact�ridgestone Retail Operat�ons. L�C Cu�'ome��<et�ntior�toil€ree at 1-Sb0-3�?�3b, r�r�,�, �
a: �^a��rv,F��c��';a�����.:�.,����b.4is��������r�+a�. ��
�°����� ���i�� �sa�ar��y��e�e
��V� r ;_J 11St� l';H[ t�l@ S�I'Vri�..� .t�.-'. �JEY�Ot�ITI Wi�� i�8 ��X��:i iICJ'�lt thB tlrS� tlr(1° (f TIIC �U[CI71ut J�� i'E.'�idll VC :�r"VIG° �JJ�S �?C'if_,��i�il�.'<$ ,� :;, _ �
tive wili re-;:�,�toi-ir� ihe s��vie;e �: ,o addit;ozial charge te you, during the es�ahiished warrai�ty period.
a'��� sE�nER�r� �����za����a-,a
`✓Ve vd � ��r � �;E �;� ,�venic-e is not ready at the :ime we promised, w� wi!i affer a 1�;-: discount�n ycur ner+
cannot �;x� eu Sz� � �+ �r�,°;�h is v�ii�i at any ccn����any-owned Firestone C;emplete Auto C�re Store. The subse<,�.� -. . � , �_
occur w!lhi ��2 �• f ��r <.�� ����= cn:�ir���l se�vice i h!s discount.carnot be �ise� to reduce outs#�r�ii�� debt.
�+�e`�t�- ?:.-e ��n',a�:'9""lP°:�il�ie �$'8� �"¢,�!.+ .Y?,.ryr gtv?tli�:
f��_.i -tS_.il. 5£r�!iCBS(`UIG"1dS��` c� �� ., . OI i7Jint.�r'=.�IfJ t�c��f.'2'�8 _.0�E ,_. 9 , ,', � _. ���F��� )I110(1tIlS 0t" i�,�i'`l:�) I; E.,
C.vi� t ., - !�� v'vl�ri sOfl18 p3f"tu Blli� Sel✓I_r.'c; _�3E yli�!'�? ci�"�I��i"211t V✓affdilY���`_i��YIE :X� i..,,l n: 1?� ' : ��IGBS@ S28 C�@t21�S EJO�OW. �V8(I�drl�i,5_,
i0 �artS lilSt�37f�i1 fatiu �c:3Vi�.� jJE;fi0iih12Q Gll �ilVaf2 pE3S52I1g@f V2TllC�@S. TI11S btif3f'r�rlty IS V8�14 8f C011lp�y"-OVvi?�"., t.i�c;SiC i.; 1������ _. _ ''�i, � _ ._
!0::3iinllc
�.�ite parts w��ch pro��e ro `,,, un���rviceabie during the warranty period, wiil be repiaced free of any additional charge for parts c, ����•�: ,. ,; ��_ .����
rioieu un�7A���=xclusiors°. b�low_
__ __ _ - - - — - _ __ -- - ___ _ ___------ --__ - �- �
' �� . _� ?,.R 5 � l � . <
_ _.__ __ -- --- -_ _ _ __ _ ---- ---- --- - _ _._ .._.-_ - -___--- - _
_ _ _,�� „ �,:r i Months� ,.0[,0 P�l I,.s;41 I 3" ±hs -
i --� -- -- __ _ —- --- - ��—=-- - _ _ _
7
2'�� .. -�1�r�� _�snti��i �iltFr. �r sr:,n �. �nir�a��ma.,, .�+�eta?eu�.�i��_, � E"��r, the � p0 Miles;4) �� o�. ,h: . �, .
an� � - '
--- -- _. - - - - -- - -
_ - ---- ------- _ __- - - - - - -
---r - -F
`�e�:, � `=!nar d,,(,.�:_d o,.���e:,a u F� �rr,a�o � ! 2 �1or�;s'"�a.G00 Miles ld) I �r... . '; ,
-___ _ _..__ ___ __ _ _ _ _ - --_ - -- - --- ----------- _ ------ ------ --------- -- - _
-
� ,
iS?annard B���t �.�,.�_ F�ia�,��S���� > C?Isr F .7�-i�I� �'� Li`etime(1) � "��:�t`�s i 12 CiQO�,��. � ,
'�------ ------- _---- -------- �
- -------------------------- --- t-- .
�tard�r 3� <F �r�� ntiB�ak.er i � `�an e E3r rc'_hoes Ds��Pa;:ef11 -- -
- � � i.�(1 i 21 i"onth� . �-;0•.� ,,,
;e�� .. �.u�:t �U�;c;„ ��xcn< <i�. �_i;��� ._��orahc�;if app i��able) " ' �
- -- _. - -- ----__ _ ._ _ -- - ----- ---._ - _ . _
�i_ifeiin e B nne e - �ake�hoc� Gi.�P..7 _.���p� � _. e� n �,;�G} _� �i�e,n E;1 I � i „f��� �+
'ar�d b ake I�siui,.iu,r ia„vdar�i"I�
'Shocr und Si�ut� , Lifetime ��, 1?�.lonths < .����L _ -
�SlBel�r�t�.:ua��e g�Jn�a,'?S � ��r.t!!Tle , �, ,'i��� '�'�
- - - -- --- _ _ _ _ - - --_----- ------ ------___ _ _-------- - --- ----- ----- _ _
��ife! . � __ ..� �!i fv 'A(2 i -ti �.�
__ _ _ _- ------- _ _ -- ._ __ __ _ - ------__- ----_ -- --- -__------ -- - _ _. _
_!ci �_ ., ,,.: oa . .-� 'LIiB[Irti°(3� . '�, l.l !f iC;��'
_____ __ __. .__ .._._---- --- --__._ . --- --- -- ----. .___.__ . .__._.._ .__.-_ ..._------- ----�--- __._. . _..__. .. . ..
�:.s�e �a��`�ss4'�� aAi€^:a��"?S�;';'Nf��P,2E �P3��.":'�9sS�ELB �'���.:°'°,.+ N_�'<`s�3�, 's�u'R'�it `e"�a�.e�@M1�,'�.;� S„a,f�Y�i'3i��'{�''Vl�PJS FF°@��V�Fi1C���
.__ .- � s; .� _r,,� _i�ts_ iu��ng� �a„�r cylinaers,i<�t��,,drun�s an�ail addtioral labor,are warrantied for a penad o�t�a !e; = � �
�G � _v�. ,z;fir__�
-
_ _ �-E� ) �,. � . �E:r�.. . e��F, � � _ - o�,vn � � .,,�,a_. �f�aits a��required io restaie��ehide[o manufacturer's specifieation>;_ �. �"�;-=. . ,
�� . < <_ , � a , .�_�,
,_
��e. ,,,.,. � - ��'� � , �� , . ��,;�r��, _.
� , ,.,, -. „ , ,
,.
� ,, =, .,. - , ��d , ��, � � =
� Monitorinq bystem�S) ---- '
�(4) Whiche��r�.omes first.
�,{atfi��r Service ir��o��-�ed�w �cx�4uss:�r�5:Repla�E �i,r.±of dn��: (eeze c-�la��r,'� �et i���.�uded � �iie wa�ranty �n belts�radia?or hoses.Cost ot re{riga;ani a� ;' rr�:^:- �
;;e�,i r�r�;tici'r�_a svs�e�i s �o cl��de�i .. ,r�the w���!a,iy on air coi��l�,i���er�y���,o�a'r oi;a�t�one� con;pressors Cosi of addi',ional brake sys�en�com�n,�„�t;
;c�io �.,���i�. .. , .i;.� ,�.:r t., r �.c,,i: _ ��K� S �<:n�tr���,._safe proper or�eratinn is,���'t inclucr.d w�tn the warra��fy�r, Brake Shoes, Cisc Pads. Cal�c. � ���c � =
��� it �_ _-� �-��-� u �;�,var:_ �_t���:; a ,.�,,. ,.���.��,a separate�n�ararry f�cm the iraru�acturer.
__ -- . _ _ _ _- - ---
_ _ ___--- -- -- _ _ ____--- ------ --------_
v?[-l�' �c��'e,:3`�2�;yr �+a'te5�'��$�vi��".5'
�i�e�,-_��rrhas.. � a� �I _•o�-: �;��ei-F,_to Ca�e�re�;overed by a li����a�}�c��R��s�'� �,��aa���ei �d�rsa�t��iro;n workmanship and��-,�.r_. _i,E.,� .
T::reS a� � ,<- cr, ���_ :��€����6��,tx�r���a �s.='la��ag� �.'s�nited ,�a�•�'��r��� v�inicf? var,es b•y tire br�n�1 and model. Int� n�aticn ��.�� ;_ �
w�rr�� r�� !� p ✓�,�� ' �Ur4'<�iy at t .e iime��f�urcfiase
:�E�ER�.L PF;O'I!SIONS(Ap;�licable to�1!w�aranties)
�ur iG _ ''�`,� h�L c'. r�+r ?�`�� �l�:�T! . u";�f _, IP�THi,; '1'JC�ti1EI��T' Tr,i, :;,,�-r� !�„�ve;,s or,l�y the o��ginai rurchase. �t 1'�e intit��le�s Gd � . ��
vli,'tR� ` ___ i�',".i�«kA��,TI!= ;�E � _ _ ,.��%ui ��nic�:, to[ne�Irestc.��e C�;r�pleie auto Care��o��e tivni^h s�id ih2 tivarran+ied p?r.�_.r , _. . �
'hH, � , _ � � ��:n:�Cr ���,�t�A�i���_;<: �..,-c�i �r����iitE��S�dtes_'";a�l��.�0�-LQk;�'��-�!�tc;iind a 4�n�pary owned I�catior:.
'�_��.r,� ,,� , ^,� , �� 8E P.r.D=�UtdD�P..TN�V•,'ARRANTI�_F�7 r��e ori,�r21 im�_ce iTo?n the stor��at wl��cr. _re o:iginal�vark�.vas}�er[� �n�c rr,.�. ��� i r. , _ , _�
�des� ���t; ;� 'h„war�ant�i-
b�;HAi OTHEf?CONDI i iONS APPLY?The obligations undertaken in these warranties�re of(ered only en the abo�ie items and conditions,and rr � roi h� �a.nec _� � , ,
by�r, � ���ar�t,�doa;men�dces not appiy to produc;ts nr vehicles used for commercial.racing,or off-road purposes,or to damage ca� � � � , _
TO T�-' r�:T=^! F'�k,'JTTED BY LAS'V.BRIDGCSTONE R�T�JL OPERATIONS, LLC,Ai�D ITS FIRESTONE COMFLETE AUTO CARE STOF«: � � ,� � ._, �
FOR �h�IOF_�aTAL R;NJ r_�->;S���2���11�PI_. DAMAGES. Some sYates do not aliow the exclusiun or limit2ticr, of incid�ntal or consequentia! di �n-.�;.
;imi[a:ion or e �� sinr� et . ,'y't���. __
CONS J^v1-��:KI�,�+'� ...vvar� ��y �,��e, y:�u speci� ,legal riahts-an�_��o�_�may a so Fiav2 otller riyhts which vary fror��staie[o state.
GIVEPd 3Y� Fir �.o� �� �, �ai._�� ,t, _;���Stores idertified in stamp or.if non�,by BridgestonefF�restone North Amencar Tire,LLC, 535 Marrio?t�.v�.`�.�-- <� �f�
, �
<<. .,_�� �n_._-�� � .�R�� �