Mealey R�C�I,IED
APR �8 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minn�s�, CL��K
Minnesotu Slute Stutute 466.05 slutes thal "...every person...who cluims dunwges,from uny municipaliry...shall cause to be pre.cented to the
xoverning body nf die municipalih�within 180 duys nfier tlte ulleged la.ss or inju���is discnvered a notice stuting the time,pluce,and
circumstances�herenf,and rhe amount of cnmpensa[ion 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 �'`f�� Middle Initial � Last Name ��ti�"'��
Company or Business Name_��
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address��3��� ���---r
City ��• i C1 l.l , State I V \ Zip Code _�' S I o 5
Daytime Phone (�)�J�e�� Phone(p�_}��-I 1� { Evening Telephone( ) -
Date of Accident/Injury or Date Discovered Time am/pm
Please state,in detail,what occurred(happened), and why you are submitting a claim.Please indicate why or h e y�o�u�
feel the City of Saint Paul or its employees are involved and/or responsible for your damag e„�.
( �� �� ���
t�.� � �' ` �
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� for com letin this form: ' ' `�"'
Please check the box(es)that most closely represent the reason p g
❑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 and/or ticketed ❑ I was injured on City property
❑ Other type of property damage—please specify
❑ Othe►-type of injury—please specify
In order to process your claim vou need to include copies of all applieable 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 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 I
and/or receipts for the repairs;detailed list of�lamaged items i
O Injury claims: medical bills,receipts I
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 comAlete this section
Were there wimesses 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 diagr m. ' � 1Q
-e�(`�p '�:'
Please indicate the amount y u ar seekin�compensation or what you would like the City to do to reso ve this cl im
to your satisfaction. ' �
Vehicie Claims— lease com lete ehis section ❑check box if this section does not a 1
Your Vehicle: Year �O 13 Make a i Model ��4��'ta -
License Plate Number State Color
Registered Owner
Driver of Vehicle MarH nG� LH
Area Damaged #��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Daniaged
In'ur Claims— lease com lete this section ❑ check box if this section does not a 1
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 �
When did you miss work? (provide date(s))
Name of your Employer: Telephone
Address
❑ 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 infotmation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submittir�g a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Completed this Form: Ma�v P � e�..�eU
Signature of Person Making the Claim:
Revised February 201 I
� � INVER GROVE HYUNDAI �
1290 East 50th St.
HYUnD�I INVER GROVE HEIGHTS, MN 55077 HYUnDAI
(651)204-4400
��STOMER No 4 516� KENR 3844 TAG NO O�� '"�°'03�11/14 �HYC5145013
LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO.
JAMES HOWARD 805 BLACK/
203 5 GOODRICH AVE YEAR/MAKE/MODEL ' DELNERY DATE DELNERY MILES
ST PAUL, MN 55105 13/HYUNDAI,/ELANTRA/4DR SDN GLS AT
VEHICLE I.D.NO. SELLING DEALEfi NO. PRODUCTION DATE
5 N P D H 4 A E 2 D H 4 1 6 0 0 6
FT.E.NO. . PO.NO. R.O.DATE
03/11/14
RESIDENCE PHONE BUSWESS PHONE COMMENTS
651-242-1951 _ � MO: 80
----._.....-•---------------------------•---------------.._...._..---------•----- THANK YOU FOR THIS OPPORTUNIT'f
---------------------------•-----....-----..
__ _ __ _______ ___ ___ _ _. TO SERVE YOU. IT IS OUR AIM TO
PERFORM ALL THE REPAIRS RE-
CUSTOMER STATES THE RIGHT FRONT TIRE IS FLAT. SHE HIT A POT QUESTED ON THIS REPAIR ORDER TO
HOLE AND THEN ONLY DROVE ON IT FOR A SHORT TIME. YOUR COMPLETE SATISFACTION. IF
FLAT TIRE NOT REPAIRABLE OuR SERVICE WAS SATISFACTORY
REPLACED THE RIGHT FRONT TIRE TELL YOUR FRIENDS, IF NOT, PLEASE
TELL US IMMEDIATELY.
PARTS------QTY---FP-NUMBER•-•-•-----•----DESCRIPTION-----------•------••UNIT PRICE-
1 1011352 205/55R16 HANKO 130.77 130.77
OPTIMO H426 TOKEN CHAfiGE
TOTAL - PARTS 1$0.�� A TOKEN CHAflGE EQUIVALENT TO A
PERCENTAGE OF OUR LABOR CHARGE
MISC------CODE------•-DESCRIPTION-•----•-------•••-----•----••--CONTROL NO-•------- HAS BEEN ASSESSED FOR SHOP SU�-
TDl TIRE RECYCLING FEE 2.50 PLIES. PLEASE SEE REVERSE SIDE FOR
TOTAL - MISC Z.SO A��ST OF THESE SUPPLIES.
JOB# 1 TOTALS-•..............................................•-•-•-••----
LABOR 16.25
PARTS 130.77
MISC 2.50
JOB# 1 JOURNAL PREFIX HYCS JOB# 1 TOTAL 149.52
MISC------CODE--------DESCRIPTION---•------------•----------••--CONTROL NO---•-----
JOB # A SS SUPPLIES/ENVIRONMENTAL FEES 1.66
TOTAL - MISC 1.66
TOTAIS-------••----------------------------------------------r---•-----------------••--•----•--- Thank You!
************************************************ TOTAL LABOR.... 16.25 WE APPRECIATE YOUR BUSINESS
* * TOTAL PARTS.... 130.77
* [ ] CASH C ] CHECK CK N0. [ 7 * � TO�At 'StiBLf�:.-: �--- -0�.00�� �— —° � �
* * TOTAL G.O.G.... 0.00
* [ ] VISA ( ] MASTERCARD [ ] DISCOVER * TOTAL MISC CHG. 4.16
* * TOTAL MISC DISC 0.00
* [ ] AMER XPRESS [ ] OTNER [ ] CHARGE * TOTAL TAX...... 9.32
* * --------
�********************************�+�************** TOTAL INVOICE$ 160.50
°THANK YOU FOR YOl1R BUSINESS!!
� "Any warranties on the products sold hereby are
" those made by the manufacturer. The seller
z (above named dealership)hereby expressly dis-
z claims all warranties,either express or impiied,
- including any implied warranty of inerchantability
or fitness for a particular purpose, and ne'ther
- assumes nor authorizes any other person to
assume for it any liability in connection with the
u sale of said products"
�
�
� PAGE 1 OF 1 CUSTOMER COPY [ END OF INVOICE ] 01:11pm
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�� `.f� Gli`� C3St,S �flC� �a�Or Cr?�ItCJeS. f-`. �� <'"��df"C� ChE�I'�e fQr �'.U�r�'J�B� =x��� ;-I1a`HI'IciiS iS fY1dC�@ Ofl eaC�l
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�����r; �ecair order in the space �rovide:�. e=�„perience ��as si�o4vn th;;; ���,r ��v��=�c�e charge covers the
� � � ,_ r`�,ese ite!�is resulting �n savings t� ot,r�ustomers.
.. ; _'_.^!'JEUUS MATERIAL F�EGULAr�L�' ��t�iSUt'JIED IN OUR SHt7P LA�C7i3 PRC7DUCTION
�.�,ers, Chassis Gr�ase �ul��k-er F'rc�ter;tor Solution
Acetylene PJ':�sk;,,y iape
> Wipin� Cietns ;�;� P!u; r ; �r°�p�;,�rds
�� `:'c�"�:�-r��--� �.��.'ax'�J:�eather Strip Cemen;
F;�; ;,v ��1a7e5 ,
- -----.-- -. -- ; � . � i..�:;����:tnunc+ --
�<_� ,��hPSive t.o�:�pound Chassis�5riims - �— � Carburetor�olvent
;•,-;�rs Dooi �,a;e
��_� ,��pcGnd Mechanic's�Nire ��P�'-�ricia��'s Tape
�;y,. � F�ende� Protectors
... ��ir�-� S�or�.
� _- A�ras�ve S?o�ies
+�;hc;��.e C!eaner
�.%ie�alr<<,� C�;a+F; Sii,�a��e Spray
Perr7�,aiox ;, ��t��:ounds T�i;;�� ,:=-�r�?e�r;t
Cau�k G�rci i'�; ': �✓����eei;>
:> �'������t �oes Into th� �ost e�� Se�rvic�ng ���r Automobile.
, ��f:s��t "just happen"! Uperatin� a deqendab!e ser✓ice business req � «;�- c.rqanization, competent
� ���ibsia�tial capitaf ir7vestm� �t, So don't judge se~vice charg�s soii' �- °,e '�me spent repairing
� � ���p �otch technician go�:=> 'o ���o�k_ many custs r�ve been inc.,r�red i��s' <<-� ��!E;i I?if?1 read`,� to Clo the
t�,�;; , o � ��-„ a
S... T a ari� �,,�itai Inv.,strneni
Wages S�.,;,:-;r�.��s�,r�y Persor�nel
BUilc�inc,� tv';ate:ials Cr�siu<:rs
��,-��.,us Lia'����tv in����,rance Clerks
Cas�,ai��:; i��•=>�_jrance ;c;�l r��<<=�
Workers c_sc•rnpensation �ru;F>?ahi.::
,,.�tio;�s �e.�erai uxes
�-;,. :
;,.,_� ;
?F�t�: -- ---- --- -----�?�tireme,it�--_ -
FiAZA�D�JU� WAS7�
� ��n�•d abouk the er�v.ronment as y��s arc Disposa! r�f ha��rd-�-,.is �vaste has become a major concern
���.,^_�.5sary to aispose af them. A charge for hazardous �,�aste renio��al r�iqht �nciude batteries, tires,
LiMITED WHi�RANTY
: �;n��,ent parts carry a 12 t�onth 12.v00 mile parts and labor li�^,i±ed vuarranty, provided by the
,'/ Minnesota Department of
! 3 , HUMAN RIGHTS �'�C���'�/��
� �"t APR 2 8 2Di4
April 22, 2014 ��TY GL�i��
REF: 60448 MDHR
444201200654 EEOC
Jerry Deno
v.
City of Saint Paul
City of Saint Paul
ATTN: Shari Moore, City Clerk
310 City Hall15 W Kellogg Blvd
Saint Paul, MN 55102
The Minnesota Department of Human Rights has received a charge for cross-filing alleging that
City of Saint Paul City of Saint Paul has committed an unfair discriminatory practice in violation
of the Minnesota Human Rights Act (MHRA), Minnesota Statutes, §363A. Accepting a
discrimination charge is in no way an indication that a violation of the MHRA has occurred. This
charge was initially filed with the Equal Employment Opportunity Commission (EEOC) and will
be processed by EEOC under the work-sharing agreement between agencies.
Should EEOC determine that it lacks jurisdiction to proceed with the charge, MDHR will
determine whether to continue to process the charge under the jurisdiction of the MHRA. If this
occurs, you will be notified.
EEOC will or may have already, sent notice of its disposition to both to the parties and MDHR.
If EEOC dismisses or has already dismissed the charge, charging party can request that MDHR
conduct a review of EEOC's decision by submitting a written request within 15 days of receiving;
(a) notice of EEOC's determination, or (b) this MDHR notice of cross-filing. If a timely request
for review is not received, EEOC's disposition will be adopted, and notice that the case has
been closed will be sent to the parties.
The charging party has the right to bring a civil suit in state district court after 45 days have
passed from the filing of this charge with the MDHR. If that occurs, the department will
terminate its processing of the charge and send such notice to the parties. The charging party
may also have the right to sue in state court after the case is closed.
Any questions regarding this notice of cross-filing should be directed to MDHR Case Support at
651-539-1117.
Sincerely,
�•
Kevin M. Lindsey, Commissioner
Minnesota Department of Human Rights
c:
Gail Langfield �
AN EQUAL OPPORTUNITY EMPLOYER
Freeman Building• 625 Robert Street North • Saint Paul,Minnesota 55155
Tel 651.539.1100 • MN Relay 711 or 1.800.627.3529 •Toll Free 1.800.6573704 • Fax 651.296.9042 • mn.gov/mdhr
�2r ��� �Ct�.�`� C�t�� �f,1L1=
R�C���/�!�
APR 2 8 2014
�`T °'�� City of Saint Paul GITY CL�F�`'
�h� '�
�m ,;;'�a�`�� �a� Application for Registration as Domestic Partners
����
We hereby apply to register as Domestic Partners.
V We have read and understand the terms and conditions of Chapter 186 of
the Saint Paul Legislative Code.
✓
We affirm that we meet the definition of Domestic Partners and are eligible
for registration.
V
1Ne have enciosed tne $20.00 registration fiee. (Checks should be mac�e
payable to City of Saint Paul.
Applicant Information ',
,
Print Name (clearly): a� � I
Signature: �� �` �� � a� �
��
Date:
�
Print Name ( e r : dk �"'
Signature: Date:
Address: abc�� '�7 � f�J� �.�jc T � �3
City, State: cS�IN�`{�f�CL, M/1� Zip Code: ��
Email Contact: �X L�' �� � � G/�'t�i�.._ �A�l
The email address will only be use� to verify spelling if printing is not legible.
Information collected on this document is public and will be available to all
requestors per the Minnesota Data Practices Act.
Return to: City Clerk's Office, 15 Kellogg Blvd. W., #310, Saint Paul, MN 55102
For information call 651-266-8688 or email cityclerkQa ci.stpaul.mn.us