Renslow RECEIVED
APR 212014
NOTICE OF CLAIM FORM to the City of Saint Paul, Min���CLERK
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,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing yonr answer to each question. If more space is
needed,attach additional sheets. Please note that yon will not be contacted by telephone to clarify answers,so provide as
mach information as necessary to explain your claim,and the amoant of compensation being reqnested. Yon will receive a
written acknowledgement once your form is received. The pracxss can take up to ten weeks or longer depending on the
natare of your claim. This form mast 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
'^i ,�+L � i , \
First Name�1 lTf 1 la Middle Inicial.�Last Name i 1 �S I�l.v
Company or Business Name
��
Are You an Insurance Company? Yes/ o If Yes,Claim Number?
Street Address � � c� �
City���.�1� .� State ��, Zip Code J�
Daytime Phone(t0�)�-�Cell Phone ( ) - Evening Telephone( ) -
Date of Accidend Injury or Date Discovered�l►'11 ��� 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 Paul or its e loyees ar involv and/ responsibl fo your ge .
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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
�(My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
❑My vehicle was wrongfully towed andlor ticketed ❑I was injured on City property
O Other type of property damage—please specify
❑Other type of injury—please specify
In order to process your claim vou need to include coaies of all analicable 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.
�Property damage claims to a vehicle:two estunates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills andlor 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—please comnlete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telepho mbers:
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 landmark,etc. leas be de ailed as possible. If necess ,attach .di
f�r� ����-iA�_P n C,���� ��C�r� ��im . - �a� . � n��n ,S.
Please indicate the amo�t you�e��ng in compensation or what you would like the City to do to resolve this claim
to your satisfaction. « �
Vehicle Claims— lease com lete this section ❑check box if this section does not a I
Your Vehicle: Year Make Model Ey�a�
License Plate Number � 3� �S� State�_Color �ao�l
Registered Owner �
Driver of Vehicle �
Area Damaged 'r re
City Vehicle: Yeaz Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—ulease complete this section ❑check box if this section dces 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 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 ���n"� � �
Print the Name of the Pecson who Co le t ' F : \_��I c� n i�
Signature of Person Mal�ng the Claim
Revised Febmary 2011
._. n. yV4VJJJ �31��� AutoNation0
*INVOICE* AutoNation Ford White Bear Lake
TROY RICHARD RENSLOW 1493 EAST COUNTY ROAD E
2475 NAVAJO RD WHITE BEAR LAKE, MN 55110
NORTH ST PAUL, NIlV 55109 PAGE 1 PHONE (651) 484-7231
HOME:458-3890 CONT:458-3890
BUS: CELL: SERVICE ADVISOR: 2697 SCOTT GOBLISCH
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RUBY RED 14 FORD ESCAPE 1FMCU9GX3EUB80157 3000/3000 157
L?Ek.QA'F£ f!R4R t}ATE VftAfiH E}�#* �20R#[�D:: ;PfX hlt9 >ftA'fE :: P�►YMEI+]'f: lN1/:I3ATE ::
18JAN14 D 20: 00 04APR14 Q CASH 04APR14
;; R.p.;;{7PEt�E€i R�Af)if < OPTIONS: SOLD—STK:EUB80157 DLR:44A121
ENG: 1.6 Liter Ti—VCT GTDI TRN:A
17: 34 04APR14 18 : 08 04APR14
LINE OPCODE TECH TYPE HOUR.S LIST NET TOTAL
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AFTER 100 MILES ;
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TIGHTEN AFTERMARKET WHEELS AFTER 100 MILES
_ ����.��'���2 _ 1.'7 .:�(l 7.7.;5 tT
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1 CJSZ*1007*A WHEEL ASY 570 .42 438 . 00 438 . 00
��1FtE CHAI�GE :� ;. ', �i� <:fl#3 ' 5 t3 :i:0(�
-1 CJ5Z*1007*A CORE RETURN 570 .42 50. 00 -50 . 00
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1 9002*1548479*0000 235/55R17 154 .95 132 . 00 132 . 00 �'
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SERVICE HOURS QUICKLANE HOURS STATEMENT OF DISCLAIMER I��CREpT#QN TdTALS
The factory wanaMy constitutes all of the � �BOR AMOUNT '�J
MON.-THUR. MON.-THUR. warranties whh respect to the sale of this
7:00 A.M. -7:00 P.M. 7:00 A.M.-7:00 P.M. item�items. The Seller hereby expressly pARTS AMOUNT �} 1
FRIDAY FRIDAY disclaims al1 warramies either express or
implied, including any implied warranty of GAS,OIL,LUBE Q .Q Q
7:00 A.M. -6:00 P.M. 7:00 A.M.-6:00 P.M. merchantability or fitness for a particular
SATURDAY twrpose.Seller neither assumes nor authorizes SUBLET AMOUNT �
7:00 A.M. -4:00 P.M. any other person to assume for it any liability MISC.CHARGES � .��
in connection with the sale of this item(tems.
BODY SHOP HOURS PARTS HOURS ALL PARTS NEW ORIGINAL E�UIPMENT TOTAL CNARGES 1 6
UNLESS OTHERWISE SPECIFIED LESS INSURANCE O . O O
MON.-FRI. MON.-FRI. u-use� R-REBUILT
7:30 A.M. -6:00 P.M. 7:00 A.M. -6:00 P.M. Y-RECVC�e� C-RECONDITIONED SALES TAX
SATURDAY CUSTOMER SIGNATURE p�EASE PAY
7:30 A.M. -4:00 P.M. X THIS AMOUNT 9:;
CIISTOMSR COPY �Gu��,(� Z�dL(,I