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Lindsey I-��C;�iVIED APR 2 5 2014 CITY CLERK NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Mi�uiesota State Statute 466.05 states that"...every persai...who claims danutges from any municipaliry...shall cause to be presented to t/ie goven�irrg body of the rnunicipality within 180 days after the alleged loss or injury is discovered a notice stati�ig the time,p/nce,nnc! circurnstances thereof,and the amount of canpensation or 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 OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name ��l NL�l.�L.j G Middle Initial__Last Name L�N D �_1( SI�'. • Company or Business Name Are You an Insurance Company? Ye /No If Yes,Claim Number? Street Address 2 '�Z L�� �V ND l�V� • City s�-��.JT �14-V L.. State M � Zip Code S � 3 Daytime Phone(��D�-�3v�Cell Phone(�),��-v� Evening Telephone(�)�- 03 g� Date of Accident/Injury or Date Discovered '' l�J -ZO Time �J���v am pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indic�why or how you feel the�,ity�Saint Pa 1 or its employees are involved andlor responsible fo yo r damages. � C L �" G : ' _ � ..- _� � 7i � — ,� S� f-c C- � $ � �� o�; � Please check the box(es)that most closely represent the reason for completing this form: ❑ 1xly vehicle was damaged in an accident � My vehicle was damaged during a tow �Iy 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 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 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$500.00; or the actual bills and/or receipts for the repairs;detailed list of da.maged 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:�nd 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? 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, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. O N V�V�V F([._S 1T`l/�6. 1N `3Arlw�' �A.uL. I�1 . S( di JAc3+C�o� S�'. W�5'7�0� l�wy '35C.�" UN�EL�I�SS , Please indicate the amount you are seeking in compensat:ion or what you would like the City to do to resolve this claim to your satisfaction. Vehicle Claims—please complete this section ❑ check box if this section does not apply Your Vehicle: Year�_Make �A��1 t,-A�� _Model �,l�V t l_CL— License Plate Number State l��Color N�,d.2oUN RegisteredOwner "����MA.1�lUt; L��ilsEY Se. Driver of Vehicle 'T� v���„�Jt�L 1 rv jZ`F-s`� S Z. AreaDamaged�Zv�.1'("�,kgs�4�CrFi2 (�.twt /El�.�� Z+l1 '� City Vehicle: Year Make _Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—please complete this section [H"check box if this section does not apvlv How were you injured? What part(s)of your body were injured? Have you sought medical treatment? s �10 nning 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 �heck here if you are attaching more pages to this claim form. Number of additional pages�_. By signing this form,you are staling 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 3" 2� ' ��� Print the Name of the Person who Completed this Form: l>�t�l .S�-• Signature of Person Making the Claim: Revised February 2011 Lindsey, Trumanue (DOT) From: Lindsey,Trumanue (DOT) Sent: Friday, March 21, 2014 8:59 AM To: lindltru@centurylink.net;t18c1381@aol.com Subject: FW: pothole -----Original Message----- From: *CI-StPaul_DSIComplaints Sent: Friday, March 21, 2014 8:34 AM To: Lindsey,Trumanue(DOT) Subject: RE: pothole Thank you for your email.Your complaint was forwardecl to public works: potholes. You may file a claim against the City of St Paul by calling the city clerk's office at 651.266.8688 or going online to: http://www.stpa ul.�ov/FAQ.aspx?QID=69 -----Original Message----- From: noreply@civicplus.com [mailto:noreplv@civicplus.com] .�. Sent: Friday, March 21, 2014 8:05 AM To'*CI-StPaul_DSIComplaints Subject: Online Form Submittal:Ask a Question/ Report a Problem The following form was submitted via your website:Ask a Question/Report a Problem Your Name:Trumanue Lindsey Sr. Your Address: 242 Edmund Ave. Phone Number: 651-303-0386 Email Address:trumanue.lindseyC�state.mn.us Please select the category for your concern.: Pothole Brief Description or question (or other problem not listed): On Tuesday afternoon I was Leaving the DNR building heading home as I turn onto Universaty Ave.traveling west as I past under Hwy 35E overpast aproaching Regions Hospital I found myself trying to avoid several potholes in the street one in patecular was pretty bad. As I avoided that one and was not aware of another one even more larger than the one I was trying to avoid was un noticed until I hit it Had damaged my tire and rim on my car.The Damage is the Front passengers wheel. I am seeking to have them replaced by the city at no cost to me for poor maintanence to the roads on our city streets considering we are paying for those problems in taxes on our tabs registrations.Also 3rd street on the east side is in worse condition I had to literaly drive very slow and stratle the lanes to avoid holes or drive the shoulder.Jackson street in the area of pennsilvania ave. is also bad. 1 Street Address: University Ave. Intersecting Street (if applicable): Describe the location in detail. (eg. behind garage, next to front steps,etc.): University Ave. North along Regions Hospital. Additional Information: Form submitted on: 3/21/2014 8:04:45 AM Submitted from IP Address: 156.98.4.11 Referrer Page: No Referrer- Direct Link Form Address: http://www.ci.stpaul.mn.us/Forms.aspx?FID=65 z v�scouNt� �I R E - - , - _ '.v`�4.�1"_..�,�� discounttire.com LAYr�L��t`� HCCi #!�-�;VY�J.J�J�'I' UATE: �4—t�i—��14 TIME: 4:3� RM . .- . .- . .- . . i r;!J}��rf,;�JE LI;���E`�! i99� CADILLAC h1CtiM �+e; �4� EDMUND f�VE DEVILLE 1�50 UNIVERSITY AVE WEST SEDA�i ALL SA I NT F�AUL MN JJ 1 K.��} SAIIVT RAUL Mrd JJ1��S F�HONE: 651-641-8916 tH) �51-3Q�3—@38� ��+,?� �OIVAH M TLfRNER TORG!UE 5PEGS: 1�2 .. . . . . *************************** THI5 IS N�T A SflLES INVOICE!—LAYAWAY DEF�OSIT ******�*��-*�-�*�******** tI'J'TOJ �R� 1 17x%.J J"1 ZJI1���►�LfSI�I LI�� �,�Fl� j� 7.5 .k�Lt 1.5�.�W iS�. �� _ w��Ran�Tve ---- ,� �-��zv�v�:�n��s_ �__�r�� �zrai�� _ _ _ _ _�— --- COMMENT: PDLT F'ATTERIV: J—SIJ �3�58 Nf1l� 1 �45/45R-17 95H R5W KUMHQ ECSTA AST .Q�Q� 71.0Q� 71.�Q� WARftAiVTY: SEE REVERSE SIDE FOR WAFtRANTY DETAiLB CDf�MENT: I NFLAT I ON F e 3: R:3� 8��17 IWRM i CERTIFIGATES FDR REFUND, REF�LACEMENT .Q�� 11.0Q� 11.4�Q� 9�`c4 NRM 1 WASTE T I RE D I SF'OSAL FEE .Q�� 3.�Q� 3.�Qa 8��1'� NRM 1 IPdSTALLATION & LIFETIME SRIIV BALGNCING .Q�Q� 1E,. �0 16.�� 8�40� NRM i VALUES/ROTATIONS/ LIFETIME REF�AIRS INCLUDED .00 .�Q� .+�0 The tire and/or� wheel yo�_� have chosen is different fram tt-�e original equipment pr,ovided with your, vehicle �nd may change its h�ndling or, st�t�ility char�acteristics. Further information is available fr�om yo�_it� Discount Tir^e s�lesperson. SUi�TOTAL: `31. �Q� TDTAL OF ALL DEF'OSITS: .Q�� TAX: 15. 34 RALANCE DUE: �'4E. :;4 TOTAL: �4E.34 AMOUIVT TH I S DE�'�5I T: . �Q� TENDERED: .�0 ��� i oo�ra recydable paper i � _ _ _ _ , � ,�fr `� �, LIMITED WARRANTIES �. .. .. .. .. .. . ., .. .. � .o .. � .. .. �� .. ..� .. � a•:� ��. : � � � � � � � � �'� � � � t � �� ' � � r r� �i!� � - ��i�l�f� �1'I�iil�l '-"il�iil�f� �I�I�i�1i �i��iii� � '�i ibiA� �iihre iiii�ir itl�'1rS niiiA ii�i��i ���r,� ii�ibr nr'l�ri Ai��r� ,,,�,4. Discount Tire and America s Tire Stores ,,,�„-�����} ,���„ f�„�� �������������_,�,��������„.�����,-��,,,� ����„ ,��� _ � ;����I�t�������1�A����r�t�l,������trG������1#6������ii1�������1�1�������1:1�1 - t�� �s,., u,a ;�i11 - ����,�,���� ELIGIBILITY-These Limi[ed Warranties apply ro all owners of the tire using �� it in noncommercial service,except for the Mileage Warranty which is limited �(� ��.,r ri i '% to the odginal putchaser. (�� :o�':� FO R R E PA I R, R E F U N D O R R E P LAC E M E N T '"��,,;s� To MnxE n cr.w�M - P�esen�yoUi tuecs>and or�g�na�sa�es�n�o��e to anv Discount Tire or America's Tire Store.To locate a store you may call 1{888)774- ( '•��� For a fee collected at the tune of the original tire purchase or for a fee collected to subject �R� �;,��y) 656Q or visit the Discount Tire web site at www.discounttire.com.The vehicle ;°!'.:.?��� other tires ro the terms of this certificate, Discount Tire or America's Tire stores will ?� on which the tire was used must be avaitable for inspection.You will be asked �j;�!!;;:��� refund the purehase pdce and the sales tazc,if any,on any tire eovered in the event of a ���y�� to complete the customer portion of the adjustment claim fornt. _--__= faiWre due to workmanship and materials or a non-repairable road hazard for the service _..'� �` � � of the original tread down to 3/32 inch remaining,or 3 years from date of purchase, �� a'�'Y COVERAGE �'�.+'•°�_-��-__� whichever occurs first.Upon refund or credit of sales ta�c,customer hereby acknowledges �'%" r:-_ -' � New Tires-Workmanship and Materials-tf our examination shows ''-'� by actual signature or electronic signature capmre such credit or refund.This additional =r `�� that a passenger,SW,or light truck tire covered by this warranty has become {���"�`�' acknowled ement satisfies a technical re uirement in the sales tax stamtes and/or t.:;�� � �i g q � unserviceable due to a workmanship or materials defect during the service - - regulations for many jurisdictions that a sigued receipt must be obtained upon the refund 4- �p down to 3/3z of an inch,it will be replaced on a pro rata tread wear basis. {�� :!"' or credit of sales taaces.At the election of the purchaser,we wiI]sell a replacement tire =�`.'�,•ji/ _: i New Tires•Road Hazard(if applicable)-If our examination shows that ===-=- to the purchaser at the odginal price paid for the damaged tire,plus the required sales =?;ti� ,`.,�+: n a passenger,SLN,or light truck tire covered by this warranty has become �'� tax.In the event the covered tire is discontinued or unavailable,a tire of similar valae will �.�'r�} aro :,�,� unserviceable due ro a normal road hazard(l.e.,non-repairable puncture,cut, be substimted. snag,bruise,or impact break)during the service down to 3/32 of an inch,it �II,.��.� � +51 [f in our opinion,the tire can be safely repaired,we will do so free of charge.The cost of �1;�� will be replaced on a pro-tata tread wear basis. -:-.� this cert�cate is set forth on the receipt issued for the purchase of tire(s). '' New Tires - Mileage Warranty <if applicable) - In addition to the � 4.•.`.'►_ "'�% �� warranties above, every mileage warranted passenger, SW or light truck _:__ This certificate will be honored at any Discount Tire or America's Tire stores.This certiticate ;-�=2_:-. does not cover dama e caused by collision,vandalism,chain dama e,mechanical defects �-`'=" tire is warranted to the original purchaser for the specified number of miles �?j;�.;;.��'. , B g �;•;���� of tread wear and against normal road hazards for the same mileage (if ��;!r_'.�_� of the vehicle or willful abuse.No other property damage or consequential damage of any ��_:.'}`.`%!` applicable).If our examination shows that the tire covered by this warranty - kind is coverrd b}'this certificate. �=� has wom down to its tread indicators before giving the specified number �'� ��� dj + � There will be additional charges to purchase a new certificate for a replacement tire and : of miles of noncommercial service on the passenger,SUV or light truck on to balance a re lacement tire. �, which it was installed,it will be replaced on a pro-cata mileage basis. ��';'�;���I P ---"'�'�� ATV/Ttailer Tires - If our examination shows that a trailer or ATV tire - _�� By redeeming this certificate,the customer relinquishes the rlght to any manufacturers y�;:;;�� covered by this wa[ranry has become unserviceable, other[han by a road {!,;.�,.;!:Y' warranry that may appl},and Discount Tire or America's Tire may claim for its own benefit .,.,'r,'�� hazard,during the three year period following its da[e of purchase,it wID any such manufacturer's warranty. = ' be replaced based on a charge of 33%per year or part thereof of the original ��� ��n 1 ,.�) purchase price. � � • � • • • ' � �i ��_�� I �� � CAI.CUI.ATION OF REPLACEMENT CHARGES - Tires are replaced -I I� . � under these limited wananties with a comparably priced new tire at a prarata � ,��.i,l D'��O���� I ` cost to the customer.Tread wear is pro-rated on the basis that t�he tire i�wom _I I�� '"� out when the tread is worn down to 3/32 of an inch remainin tread roove depth or to the vead wear indicators on tires contaiaing them.Tire replacement i:i%�»r '��;-:i:ii;�t � � cost is determined by multiplying the original wst of the tire by the percentage ' ,�_ � � � � � = of tread used.For example,if the origic�al�ad was 11/3�of ap inch,and the , � ,� tire has 5/32 of an inch of tcead remainin at the time of re lacement, the +'4��-.� �_s?:_.;�% replacement cost will be 75%of the original cost((11/32-5/32)/<l l/32-3/32) x 100).The replacement cost for mileage warranted tires is prorated at a set �� ���I �'� '���� charge per 1,000 miles driven.F.E.T.and state t�es are added to the replacement �I tI��III tIiRR: lir�{mm n3 ilrr m��imtIIt�lTrilll��itmi� j?������� ���„f wst.Additional charges for mounting and balancing apply. 1H��NM1�Wi11�NuNt+INt�1'�rwN���NrN HnN � NN�e1'fl'lul� NN11 InN iil�li�1NN1 .�.IUN1 (i� ' �7����a ;}i����,�,� ������� u�,��� �FNV��i laer„ uu��� a�������,�� �Nr��w� �iu��r �����N ���rN�� 1�,i1N �.rN,��� ������� ��Ni1,r�:.,H,�r ` � ,.. .�., , A. .�. .�. ,.4. .�. .�. .� + .�, A. ,.�. .�. .�r .�. .�•, .�. .., t!) : .�_ = . ,. - _= -. -- - �.,,_ -�-,_ _; : ` _�.�� ITEMS NOT COVERED-These warranaes do not covec � v The cost of any[ire includes any wheel weights used in the balancing of the tire. ` • Use i�commercial service such as commercial truck racing,street sweepers,off-the-highway taxi,limousine,or similar service(however commercial service does not include use by the owner as transportation in his/her regular[rade or business); TI PS TO I M PROVE TI R E ' Damage,destruction,or failure due to accident,fire,or vandalism; • Irregular or premature aead wear caused by improper inflation, M I L EAG E A N D SA F ETY misalignment,imbalance of wheels,or worn out shock absorbers or brakes; • Damage or failure due ro non-tire causes such as being run Fla[,mechanical condition of the vehicle,cuts from rims or chains,or any willfid abuse; • Problems related to the appearance of the tire aher the First 10%of wear. �ROTATE TIRES � REPLACE every 6,000 to 8,000 miles or when wormout tires when built•in wear bars OWNER'S DUTIES-It is the owner's responsibility to: necessary to equalize treadwear. appear across the tread surface. • see cnac cne ures are ope�acea ac proper intiazion,pressure and loads; ��REBALANCE �� REMEMBER TO RETURN ' Pay applicable taxes and dealer services such as mounting and balancing; every other rotation to promote even to any Discount Tire I America's Tire store ' Return the adjustable tire and complete the customer portion of the tire wear and a smooth ride. for a tire inspection. adj�scmenc cia;m torm. DURA1'ION OF COVERAGE-These warranties expire three(3)years from �MAINTAIN AIR PRESSURE � the dace of purchase. as recommended by the vehicle or tire � CONDII'IONS AND EXCLUSIONS - These limited warranties are �ne manufaeturer.Cheek your air pressure at least � � � � exclusive warranties of Discount Tire or America's Tire stores,are in tieu of the once eaeh month when tires are cool. warrancies of che mam,eacmrer,and set forth the exdusive remedies available to the tire user.In the event that the terms of an applicable manufacturer's wananry �!MAINTAIN ALIGNMENT exceed the protection given under these warranties,Discount Tire or America's Tire stores will honor those terms.Discount Tire or America's Tire may claim (Front&Rear)replaCe worn SuSpenSion partS. ' " L ' for its own benefit any such manufacturer's warranty These limited warranties � �HECK�°S�� do not provide compensation for any wnsequential, special, incidental or �j'�PLEASE DO NOT USE A'R � contingent damages. Some States do not allow the exdusion or limitatioa of V incidental or consequentia(damages,so the above limitation or exclusion may dfly"Fix-a-Flat"type products. ��p�ES� ���t not apply ro you.Tires presented for a claim remain the property of Discount � � Tire or America's Tire Stores.No representative or employee of Discount Tire or �INSPECT ����,� America's Tire Stores may enlarge or alter[hese warranties. tires oceasionally for excessive wear,tread CONSUMER RIGHTS - These limited warranties give you specific legal or sidewall cuts,or other damage. r;gncs,and you may also have other rights which vary from State ro State. veloche chrome rims - Google Search Page 2 of 12 '�`s` �;�' � `� >. ;�� �� ��"� � � , � ^��. , �' 4. �Si. .s? y > ��r` i ,�� �, ;"��,"`,. � '�� ,5 �� ;����E �� '`"� J, ,�� -i�` ,' ,? �;,�M� �,.,,��'� , � �., `� �t � � �. f �''. 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