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Ballas R�CE��I�D NOTICE OF CLAIM F'C)I�M to the City of Saint Paul, Minnesota�'5 �0�4 Minnesota State Statute 466.05 states that"...eve erson...who claims dama es rom an munici ali shall cause to be �sente�o���� �'P S f Y P h'... p governing body of the municipaliry 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 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 � _ Middle Initial�Last Name ���� Company or Business Name –���— Are You an Insurance Company? Yes No If Yes,Claim Number? Street Address � ` ����I�I� c�T- � � �p p C ,, City�fi.��1�� State {V'\� Zip Code �c� Daytime Phone ( ) - Cell Phone (�)_�-f��S2� Evening Telephone ( ) - 2�� �Il � Date of AccidenU Injury or Date Discovered�`� � i V /.�) Time � •?�' _�ji /pm Please state,in detail, what occurred(happened),and wl�y you are submitting a claim. Please indicate why or how you fe�he City of Saint Paul or its em�loyees are involved and/or responsible or your dama es. � ' 1�C1 �( � � Y\ t 't b U ��c L ' 1 Y �G Uf �r. Please check the box(es)that most closely represent the reason for completing this form: ,0'�VIy 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 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 aunlicable documents. For the claims rypes 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 far yourself before submitting your claim form. ,f�P'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 dama�od items O Injury claims: medical bills,receipts O Photographs are always welcome to document�nd stY�port your claim but will not be returned. Page 1 of 2–Please complet��d 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—ulease complete this section Were there witnesses to the incident? Yes No �nknow (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement c�,lled? No Unknown (circle) If yes, what department or agency? �, Case#or report# �'l '7�L� �(��'L 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. �� '�1Lk0�i��1 `i�'. � 5�-'Pau�, i�rJ . 2 bi���; �vau�, ��,�n� fil�. C�r� S�c�k��+� Please indicate the amo t you are eking in compensation or what you would like the City to do to resolve this claim to your satisfaction. � '�J�s� Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year�Q�Make 1�(7Y1G�01 Model �( License Plate Number `1(�:.T '�y2 State�_Color I�IfAt,Y1 Registered Owner G� G1 Driver of Vehicle 1�Al�.}1U 13UI1U5 ��1.� v'J(A5 1�(Af4t,et� fJ�i' �j C�r �A 11 k- Area Damaged �t�d e 1( `jv�Q„ V�A�t'�C i tSY 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 check box if this section does not ap�iv 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 �heck 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 ���i L���v�I� Print the Name of the Person who Completed t ' �,E�in,�h(� y 'lUl J Signature of Person Making the Claim: �' + Revised February 2011 � II American Auto Service Page 1 of 2 1036 C�rand Ave. If1V01Ce ST.PAUL, A�N 55105-0000 28535 � , Phone: (651)298-0766 Fax: (651)224-9200 Estimate Ref#: 28,841 Email: all.american.auto@comcast.net Date Printed: 04/23/2014 Web Address:www.allamericanautoservice.com Printed Time: 12:14 pm Hat/Ref# If you like our service please write review on Google for 5.00 off your next oil change. Time Promised: Ballas, Matia 2000 HONDAACCORD EX L4 2.3L 2254CC FI GAS N F23A1 99 Victoria St. N. VIN:1 HGCG3252YA015254 Date Written 04/07l2014 SAINT PAUL, MN 55104 License XRT142 Mileage In: 0 �/�/ritten By:John R. un�t#: Mileage Out: 125,712 Cell: (651)210-5824 Email: poM Save Old Parts: No Job Name Description Technician Qty List Extended Left mirror. Left mirror. John R. Part 26100427 Left rear view mirror. 1.00 $108.00 $108.00 Note/Title Mirror comes black-may not match exact color! Labor 1 Work Requested-Left mirror. 0.40 $105.00 $4 Work Performed-Replace mirror. Job Total $150.00 4.5 GOF 5W30 Bulk 4.5 Qt. 5w30 oil change. John R. Misc OF Work Requested-Check all fluids and 1.00 $9.50 $9.50 tires,change oil and filter. Part 5W30 bulk 5W30 oil. 4.50 $4.19 $18.86 Part 21334 Oil filter. 1.00 $8.50 $8.50 Part 9100 Honda power steering fluid 1?oz. 0.25 $4.95 $1.24 Part Coolant Qt. Quart Coolant 1.50 $3.99 $5.99 Part Brake fluid 12 oz. brake fluid. 0.25 $4.49 $1.12 Note/Title Recornmend pressure testing cooling system to determine if coaling system has a leak! It was 1.5 quarts low. Job Total $45.20 Recommendations Job Name Description Recommended Date Mileage Note Coolant was 1.5 qts. low on 4/7/2014 April 07, 2014 125,712 Check engine light was on when oil was changed on 4/7/2014 Engine has ticking sound! All American Auto Service Page 2 of 2 - . 1036GrandAve. If1V01C2 ST.PAUL, MN 55105-0000 28535 Phone: (651)298-0766 Fax: (651) 224-9200 Estimate Ref#: 28,841 Email: all.american.auto@comcast.net Date Printed: 04/23/2014 Web Address:www.allamericanautoservice.com Printed Time: 12:14 pm Hat/Ref# If you like our service please write review on Google for 5.00 off your next oil change. Time Promised: Ballas, Matia 2000 HONDAACCORD EX L4 2.3L 2254CC FI GAS N F23A1 99 Victoria St. N. VIN:1 HGCG3252YA015254 Date Written: 04/07/2014 SAINT PAUL, MN 55104 License: XRT142 Mileage In: 0 �/ritten By:John R. un�t#: Mileage Out: 125,712 Cell: (651)210-5824 Email: ooM: Save Old Parts: No i Parts: $143.71 Labor: $42.00 Payment Date Type Method Amount Sublet: $0.00 4/8/2014 Other 213.42 Misc: $9.50 Payment Totals: $213.42 Hazmat: ' $2.00 Supplies: '` $4.88 Tax Total: $11.33 Invoice Total: $213.42 Less Paid: $213.42 Balance Due: $0.00 Like us on Facebook!!