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Smith, Sharon � RECEIVIEp APR 2 4 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Min��o`CaCLERK Minnesota State Statuie 466.05 states that°...every person...who claims damngesfrom any municipaliry...shall cause to be presented to the gwencinK bo�v uf the municipulih�withir�/RO du��s ufter the ci/lexed loss ur i�ijun�is discuvered u�tutice stuting the tune,pluce,mid circunistances thereof,and the nmount of eompensation a�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 additiona!s6eets. Please note that you wi11 not be contacted by telephone to clarify answers,so provide as much information as necessary to exptain 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 compieted. 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 PALTL, MN 55102 First Name�,Q��1 Middle Initial�._Last Name . 11�\1. Company or Business Name Are You an Insurance Company? Yes No If Yes, Claim Number? Street Address l�� ' City C?�� State�� Zip Code �) Daytime Phone�)�--��'Cell Phone( �� -�� Evening Telephone(�.�- �I�J 1 Date of Accident/Injury or Date Discovered �\\�� `� Time `�� am/ t� Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how ouo feel the City of Saint Paul or its employees are invo�ved and/or responsible for our damages� ��' ' �• `�� ' �.tt�. '�� 4'GJ`c•i n .�1ai� �, o. � � �G � � � �� - � \ � �� bJ o. �t.�o � �vJ�� 5� t,,; ` �a �� ir .� , ,` � I�-�� . A � •�ti� �r �F�� '�`C� ` � � 1 �• � � ;y,� Q� �n (�`�GJ�.1 ��`�, Q�� `(L�\GG, �r � V�A @� d''�-C� i� , \ �'��\,e wQS. h- ��'� �c�.Da � ' Plea�e check the b x(es)that most close y represent the reason for compl ting this form: �M❑ y vehicle was damaged in an accident ❑ My vehicle was damaged during a tow y 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 rype of property damage-please specify ❑ Other type of injury-please specify In order to process your claim vou need to inciude copies 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 the repairs to your vehicle if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims: two repair estimates if the damage exceeds$SOQ.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—alease comalete this section Were there witnesses to the incident? Yes No Unknown (circle) Pr vide their names,addresses and telephone number : �� -5 W�u�t Were the police or law enforcement called? Yes No Unl�own (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street,interse tion,name of park or facility, c osest landmark,e . lease be as d iled s ppss�ble i�nec ssary atta a diagram.��,U.�1�.��ar�j0�i.�i ��J�q�QC� 1�� Y ��.�� 1�. ��,k� �n1� ��,�� .0��"� � Please indicate the�ount you are seekin in compensaf � �`w t you wo�u e th�Cit�to�d �tQ r lve t�i cl ' �� to your satisf ti n. 0 � � �� `�� j� � � �.�� '�1 Vehicle Claims— le e com lete this tion ❑check box if tlus section does not a 1 Your Vehicle: Year Make � Model License Plate Numb - ` te�Color Registered Owner � Driver of Vehicl �b 'f�i Area Damaged � •\ �� "M City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims alease complete this section heck 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 i 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 �' �U'� Print the Name of the Person who Completed this Form: ��6� ��""� Signature of Person Mal�ing the Claim: C�� J'�.'�'\ Revised February 2011 f __ __ _ � � _ __ � __ - fi __ g_„�.. _ . � \�� `��----_�`��-V�`�� TM �"►��.� `��'�,.�.-�:_ . . . �� }�°. ��t,,� t��.� , , __ . - _ __ _ _ �__ �_ _ �__ _ __ . � \ � . fi E,y� . . .... .. . .. .... ��'Z YJa_�4 ?��. ��._'.. ___ � �'._. ��Y.�.�__ t�y_".__. _!i`� ��.K_ . � j _._. . - � -�---- .. _ __.__... . . .. . . . . ... . ... __.__. _ _.__ . ._.___.. .___-- -----� �----- �----- -_�--1----------��----- �--�--_. I _ . . . _ ._ . . . . t ._ . .. . . . . . _ _ . .. .. . ._ _.._ .__.. _...._.__.. .... . . _ _ . . . .. . _ . . ._ .._ . .... . � . ..._ ._._ . . _ .. . __ _. . . __. .. . ._...... Customer Invoice TIRES PLUS Service Advisor: 1161�35 � MIDWAY �'��`�,' 07 MATT. 03/14/2014 300 SNELLING AVE N 651.644.1975 SAINT PAUL, MN. 551045330 Re-Printed on os�27�2o,a o�:4s Pnn DUPLICATE INVOICE 2009 CHEVROLET MALIBU LS SMITH, SHARON 4-146 2.4L DOHC 82 COOK AVE W Lic#: 460DRX MN Vin#: SAINT PAUL, MN 55117-4929 In: 03/14/14 7:40PM Mileage: 81,536 651.488.9155 Out: 03/14/14 8:03PM , Store#244226 RETAIL SALE Rev Hist Unit Extended Job Description /Article# I _Qt� Price Price Total __ — __ _ __ __ __ _ _ - - -- - --- — -- BRIDGESTONE TIRE PACKAGE 07 21 . POTHOLE CUASED SIDEWALL FAILURE TO TIRE 144730 ECOPIA EP422 BL P225/50R17 93V 65,000 Mile 144730 95TN 1 176.99 176.99 Limited Warranry DOT# V6YAE260714 UFETIME NEW TIRE WHEEL BAL�ARTS 7025194 95TN 1 ` 3.99 3.99 LIFETIME NEW TIRE WHEEL BAL-LABOR 7001725 95NS 1 13.00 13.00 7040215 ROAD HAZARD WARRANTY 7040215 95TN 1 15.00 15.00 SCRAP TIRE RECYCLING CHARGE(1) 7075078 95TN 1 2.99 2•99 LOW PROFILE TIRE INSTALLATION 7006472 95NS 1 N/C N/C COURTESY CHECK 07 COURTESY CHECK 7046930 95NS 1 N/C N/C Technician(s): 95 AARON BAKKEN Payment History: Summarv: Visa 4768 227.92 895795 Parts 195.98 Labor 15.99 Total Tendered 22�•92 - Shop Supplies 0.78 Sub-Total 212.75 Tax(7.625%) 15.17 Total $227.92 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. `1 � ��.��; �� Customer Signature �Initial here to indicate you have received the Tire Warranty Maintenance and � Safety Manual. All parts are new unless otherwise speciFed. www.T'iresPlus,com Paee I of I Q . a �- s _' S }}_..__ �� u��j�, �__� �� 'r , E _ --— F � _� � � . b.a _ —_ _ x r �; . ,_ , � � �, - s ��'��- � �'�� _ � �=� � _�� ___ �� —- —_ — _ _ _ _ � . `�� , �. �-�. � � � _ _ -.��.--- � --- - --- - — -- - - s_ ----__ __ _ ____ - -- �tl �. . _ _ __..��. _' ��-- _ ._.-_ � S��L r. i' _.... .. . . ..__ ... .. .--___ ._.__ - i.,s�� .�� .. _ ___k�� '�� ___ �� :_ ��`�: �.� _ _ � �� ., _� ��,!`° ��--� "�"`��`�j---- �y�-0 >�,...�.. �,,. ��`� �� - `� __ -- . . � � _ _ _ = - ---- --- -- ---�__ �`�,�-�� _�.�� ._ �`'� _ .��__ - � _ g� � t�� ` _ � �' A��L! _ �`�-��''�.� 'k __�_� ��_e . ..� —---- c��—� -- -- _ _ — -- --- -- ---- -- — --- � _ �'��... _ - �_�__��Q�i�—� �-- _ _ _ _ _ _ . t __ __— _-- _ I _ _ __ _ _ I _ _ _ _ _ _ _ _ _ �. y � � 2 Custc�mer ir*voice TIRES PLUS Service Advisor: 116611 � MIDWAY �� 07 MATT. 03/27/2014 300 SNELLING AVE N 651.644.1975 SAINT PAUL, MN. 551045330 2009 CHEVROLET MALIBU LS SMITH, SHARON 4-146 2.4L DOHC . 82 COOK AVE W Lic#: 460DRX MN Vin#: SAINT PAUL, MN 55117-4929 In: 03/25/14 6:10PM Mileage: 81,618 651.262.4139 x1 Out: 03/27/14 1:46PM Store#244226 RETAIL SALE Rev Hist Unit Extended Job Description_ _ _ __ /Article# ID Qt�_ _ Price_ _ Price Total ---- --- -- ------ --- __ _ . _ _ - - WARRANTY FLAT REPAIR(ROAD HAZARD) 07 ROAD HAZARD FLAT REPAIR 7001123 44NS . 1 N/C N/C COURTESY CHECK 07 COURTESY CHECK 7046930 44NS 1 N/C N/C WHEELS 1 07 150.00 RIM IS UNREPAIRABLE FROM IMPACT TO POTHOLE ALLOY WHEEL 7017868 44TN 1 150.00 150.00 GOODYEAR TIRE PACKAGE • 1 07 126.98 NEW TIRE WHEEL BALANCE PARTS 7018708 44TN 1 3.99 3.99 NEW TIRE WHEEL BALANCE LABOR 7018716 44NS 1 9.00 9.00 SCRAP TIRE RECYCLING CHARGE(1) 7075078 44TN 1 2.99 2.99 LOW PROFILE TIRE INSTALLATION 7006472 44NS 1 N/C N/C 7099717 GOODYEAR ASSURANCE 225/50R17 7099717 44TN 1 111.00 111.00 DOT# M740JY1 R4013 MISCELLANEOUS TIRE RELATED ITEMS 1 07 -223.52 7099684 CUSTOMER REFUND-TIRES 7099684 44NN -1 223.52 -223.52 Technician(s): 44 SAM BRAU Payment History: Summary: Visa � 4768 74.43 701268 Parts 41.47 Total Tendered 74.43 Labor 11.99 Shop Supplies 0.54 Sub-Total 54.00 Tax(7.625%) 20.43 ' Total $74.43 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 agre ment with the issuer. Rev �� Revision History: Amt Init Customer Signature 1)03/27/2014 10:10AM 54.43 SMITH, SHARON 651.262.4139 �Initial here to indicate you have received ' the Tire Warranty Maintenance and Safety Manual. All parts are new un/ess otherwise specified. � I acknowledge notice and oral approval of an increase in the original estimated price. Signature or Initials ww�n�.Tire�Pius.��r� PaPe 1 of 1