Olivares RECEIV�C�
APR 212014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes�Y CLER�°;
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...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,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete tlus 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. Tlus form must be signed,and both pages completed. 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 ���C1 E'-1�� Middle Initial�Last Name � � �v�'R�S
- - -- - _ - — _ __ __ - -
Company or Business Name �,�
Are You an Insurance Company? Yes�If Yes,Claim Number?
Street Address �Z� �o�+'Yl �� - � �
c;ty 5� - �c-��.\ s�ce M� v�v�� so� Zip Code 55I b fv
Daytime Phone(�Z-�4 2.-�ell Phone(_) - Evening Telephone(� -
Date of Accident/Injury or Date Discovered �� � �l� Time�_am/�
Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how you
fee the City of Saint P ul or its employees aze� v lved and/or responsi e for your damages. � Gt �I'
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Please check the box(es)that most closely represent Che re on for com ering this form:
❑�v1y 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
C7 rvfy vehiele 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 vou need to include copies of all annlicable dceuments.
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 dama.ge 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 issuecl 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—nlease comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
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,
clos st landmark etc. Please be as detailed as possible. If n cess ,attach a diagram. Gt �
C (� �G�'7 �GL� 0 Gt S' r �r �
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Please indicate the am n ou e seeking in compensatio or what you would like the City to do to resol this c aim
to your satisfaction. � — LD.S �Z° / �'-�1�!'1
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year Make Mode���
License Plate Number State Color
Registered Owner �
Driver of Vehicle �
Area Damaged � � �r�
City Vehicle: Yeaz Make 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)1
-- - - ---
__ Na�e�y�ur�mployer: _ __
_ __�_�.�__ .
Address Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all information you have provided is tnce 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 Completgsi..thi, + •m: � (j�
Signature of Person Making the Cl '
Revised February 2011
* INVOICE * #134?57
TIME IN/1�PT:
'.gES PLUS DUE TIME:
�05 SILVER LAK� ROAD
_NNEAPOLIS, MN 55421 WAITING / DROP OFF
i. 612-789-436I
�ache@knapquist.com
;Jw.tiresplusminn.com
ACCOUNT#: 105479
-Sold To: DA� : 04/09/14
xUMBERTO OLIVARES IATVOICE #: 134757
1903 GRANT � 55112
NEW BRZGHTON, P1N ph: (651)246-0060
Billed By: G SUNDEEN S#:l Rt:
Salesman : GILL SUNDEEN Ct:R COD: IWS:
2008 MAZDA MAZDA6I Tx:Y EX#: parking Space#:
040BN Mileage: 8?941.0 KID#:
vIN#: lYVHP89c785M39173 Extended
Unit
p=ice F.E.T. Amount
TC MC DF BIN� 107.00 107.00
Quantity Product # Size)Desc=iption/Mfr# 1 L 26.00
l.p 311B9 P215/54R17 RIREN RAPTOR VR y � N4 C��E!
TPP PARTS TIRE PROTECTION PI,AN 1 L D 2.99
1.0 YSTH+ PARTS VALVE STEM L R 2.99
RIgg RECYCI,S FEE 2.99
1.0 TRF FE& 1 L E NO CNAR6E!
S80PSOFPLY SHOP SUPPLY TIRE FEE L � :
400-MB DISMOUNT 6 1'iOtlliT TI� L Z
Dismonnt tire from rheel. Clean and L Z
inspect bead of xheel. Install nep � Z
valve stem. Inflate to prope= PSI.
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400-t� LI��� ��E L ti 38Q5 SILVER IAKE ROAD
Remove wheel, computer spin balance. �p��{ONY MN 5�71
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Alignment Check 6 Vehicle Inspection.
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SEQ: Ou9013
?ASSENGER FRONT pppROVAL CODE: S1'JIPED
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� aehicle. AM�JUNT
PRODUCT QTY PRICE 162.81
GEN Atl�O MERCH ._......._..
Re°ei°ed BY: TOTAL AMOUNT: �162��1
APPROVED 009013
THANKS FOR YOUR BUSINESS
CUSTOMERCOPY _ , ,._-,.. ;.