Willy RECEIVED
x TI E OF CLAIM FORM to the Cit of Saint Paul Minnesota12014
NO C y ' CITY L (.�K
Minnesota State Statute 466.05 states that "...every person...wlu�claims damageS f/'0711[lYly IYLUiIZCZrIQllly...Shall cause tn be prese�eT'�he
governirtg bndy nf the municipality within 180 days after the alleged loss or injury is di,rcovered a notice szazing tlze time,plaee,mtd
circu�nsrances therenf,and zhe amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typit�g 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 OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �r�Y Middle Initial�Last Name ��� �
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address ,�.� 1 d ��aVl ���e rl ./��� �
City �'f i �� � State �� Zip Code � �
Daytime Phone(�C,Z )���_Cell Phone( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered � Time`= `00 am pm
Please state,in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how you
feel the Ci�,y of Saint Paul or its employees are involved and/or responsible for your damages.
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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 during a tow
�,�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 prope�ty
❑ Other tyFe o�properry�amage—please spec,`ify --
❑ Other type of injury—please specify
In order to process your claim y�:: ^pQd to include coUies of all applicable 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 die 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 ticke�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-please complete this section
Were there witnesses to the incident? 'es No Unknown (circle)
Provide theu names, addresses and telephone numbers: t���e�Ie YA�.�oi�,�f� ('S00' 3��
Were the police or law enforcement called? Yes � 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 landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. �,�C� �', Lci�d
�,Y����r, A� rl�o , �,,�T.� ��; �,�d.��� Bv�. ��c e ti'�,
Please indicate the amount yo are seeking in compens 'on or what you would like the City to do to resolve t is claim
to your satisfaction. � � E � °' � �"
Vehicle Claims please complete this section 0 check box if this secrion does not applv
Your Vehicle: Year 2 0l2 Make C�1�(S�r' Model Zoo
License Plate Number - State Color��I/C'Y
Registered Owner Y'�e Y � �
Y
Driver of Vehicle e
Area Damaged�✓'��1� i'��� Y';V''�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims qlease 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
I�Check here if you are attaching more pages to t°s claim form. Number of additional pages�.�.
By signing this form,you are stating that atl 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 ��
Print the Name of the Person who Completed this Form: ��1'2y Wr(�y
Signature of Person Making the Claim: �-�-� ��.-���'�
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Revised February 2011
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Customer Invoice TIRES PLUS Service Advisor:
117182 MIDWAY 73 GABE
04/10/201'4 300 SNELLING AVE N 651.644.1975
� SAINT PAUL, MN. 55104-5330
WILLI, JEFF 2012 CHRYSLER 200 LIMITED
1190 VAN BUREN AVE Lic#: 1 MN Vin#: 1C3CCBAB8CN138462
SAINT PAUL, MN 55104-2012 In: 04/10/14 11:24AM Mileage: 1
612.578.9244 Out: 04/10/14 11:27AM
Store#244226 RETAIL SALE � .
Rev Hist Unit E�ended Jo�
Description /Article# ID Qty Price Price Total
_ - - -- - - - -- -- -- - -_
--
WHEELS 73 141.99
5105665aa CUSTOM WHEEL 17 INCH STEE� RIM 7000620 73TN 1 141.99 141.99
BASIC INSTALL PACKAGE 73 � 17A7
WHEEL BALANCE PARTS 7005989 73TN 1 3.99 3.99
RUBBER VALVE STEM 7015040 73TN 1 2.99 2.99
SCRAP TIRE RECYCLING CHARGE (1) 7075078 73T1� 1 2.99 2.99
WHEEL BALANCE LABOR 7006010 73NS 1 9.00 9.00
TIRE INSTALLATION 7015016 73NS 1 N/C N/C
PRT-DISC DISCOUNT BASIC INSTALL PACKAGE 7001665 73T -1 0.70 -0.70
LBR-DlSC Q�SCQG"vT BASIC INSTALL �A�KAGE 7001665 73N -� 1.20 -1.2�
COURTESY CHECK 73
COURTESY CHECK 7046930 73NS 1 N!C t�i/C
17 INCH STEEL RIM
Technician(s):
73 GABE LOPEZ ,
Payment History: Summary:
Visa 5605 171.05 031196 Parts 148.27
Total Tendered 171.05 Labor 10.7�9
Shop Supplies .0.4�
Sub-Total 159.55
Tax(7.625%) 11.50
Total $171.05
I have received the above goods and/or services. If this is a credit �
card purchase, I agree to pay and comply with my cardholder
agreement with the issuer.
, Customer Signature
All p�rts are new un/ess otherwise speci�ed. - - -
�
TELL US ABOUT YOUR EXPERIENCE TODAY AND ENTER DRAWING FOR�5001N SERVICE!
Call 1-800-754-9817 or go to www.TiresPlusSurvey.com; Enter code 244226-117182
Offer expires 10 days ftorn date of invoice. Good at all participating locations. .
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