Dinzeo R�C�IVE�
APR 2 9 2014
NOTIC� OF CLAIM I'ORM to the City of Saint Paul, Minnesota
CITY CLERK
Minrtesota S�ate Stuti�te 466.05 stntes that "...every person...wlio clnims dcirncige.r.`i�om any municipnlity...sliall cai.�.re to he/�re.sented�o the
go��erning budy q/'t/ie rnunicipa/iry x�ilfii�i I80 dups nfter the aNeged loss or injtrry is discovered a no[ice stnting the time.pince.nnd
circt�ntstnnce.s tltereof,nnd tlie amou�tt of compensation or other relief demnnded."
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 th.�t you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to expiain 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 y�Last Name //1/1.� �. �O
Company or Business Name �
Are You an Insurance Company? Yes/ o If Yes, Claim Number?
Street Address e�_���1���_ � fi � 2-��
p r/
City �� 1 A��� State �/l.� Zip Code��r 0�.�.
Daytime Phone (�) Z-�- '�4 Cell Phone�---�'"- - Evening Telephone (�)��-��'��
Date of Accident/Injury or Date Discovered �'— � ' � � Time�am/�m
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 employees are involved and/or responsible for�ur dama es. � ���l � -1�
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Please check t'he�ox(es) t�iat most cIosely represent the reason or completing this rm: ► � u �
❑ My vehicle was damaged in an accident ❑ My vehicle was dam• uring 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�u need to include copies of all apulicable 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
. ' of dama ed items
and/or recei ts for the re airs; detailed]ist g
P P
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
I'ailure to complete and return both pages will result in delay in the handling of your claim.
AU Claims-please comn�ete this section
Were there witnesses to the incident'? Yes No nknown (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 p s:'b . If necessary, attach a diagram.
Please indicate the am nt you are seeking in c mpensation or what you would like the City to do to resolve this claim
to your satisfaction. ���'�..�e
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year ZOL! � Make��(J, Model .
License Plate Number �C� "�Z� State�_Color ��j�� �1 �oQ
Registered Owner iur ' h �,�J V S' /7�nt���Z.-EC�
Driver of Vehicle � � � tl��1 � �G'
Area Damaged ` �Fr ��2�N � ��EL-
City Vehicle: Year Make o el
License Plate Number • e Color
Driver of Vehicle (City Employee's e
Area Damaged
In_iurv Claims-please complete this section l�check box if this section does not a�plv
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
VVhcn did you m;ss work? - -- - (provid�date(s})-
Naine of your Employer:
Address Telephone
�j Check here if you are attaching more pages to this claim form. Number of additional pages�.
By sig►zing this form,you are stating tliat ull information you have provided is true and correet to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �—� -- j �
Print the Name of the Person who Completed this Form: R IV ��'1 O�I,�� T. D �l� �E L
m
Signature of'Person Making the Claim: �
� Revised February 201 1
i
tf11�II�UUUII Iliqr�
�'�e• STILLWATER AUTO CLINIC SERVICE ORDER 116849
���`��� �" 12430 55th.STREET NORTH 3 Apf 2014
r°
� OAK PARK HEIGHTS MN 55082
. 1 (651)351-7188 We are open Monday thru Friday 7am to 5pm
Our Company Appreciate Your Business
www.stiliwaterautoclinic.com ORIGINAL DATE: MONDAY,31 MARCH 2O14
COMPANY 3714 EMPLOYEE
CUSTOMER DINZEO TONY YEAR 2007
ADDRESS 240 SPRING STREET#218 MAKE CHEVROLET
MODEL COBALT
ST.PAUL MN 55102 LICENSE PLATE XCX729
TELEPHONE(S) ( ) -651 V.I.N. 1G1AK55F177397107
(651)224-0617 DUE BY 4 Speed Automatic-Front W...
KEY-HAT NUMBER 3_$ 3 Apr 14 00:00 MILES IN AND OUT 69622.00 � 69624.00
TYPE DESCRIPTION I PART NUMBER I MISCELLANEOUS QTY TECH. SALE EACH SUBTOTAL
P 9595091 -HUB CAP 1.00 29.95 $29.95
P WHLX42540-STEEL WHEEL 1.00 99.95 $99.95
P FILAF2956-AIR FILTER 1.00 14.95 $14.95
TYPE DESCRIPTION/PART NUMBER/MISCELLANEOUS QTY TECH. SALE EACH SUBTOTAL
L REPLACELEFT FRONT WHEEL, MOUNT AND BALANCE 02 $150.00
TIRE, REPLACE HUB CAP, INSPECT FRONT END AND
BRAKES, RESET ALIGNMENT AND TEST DRIVE.
ORIGINAL ESTIMATE $0.00 X:
REVISED ESTIMATE $0.00 31 Mar 14 16... X: ORIGINAL ESTIMATE
RECOMMENDATIONS
3 Apr 2014 - ... - 0.00
I hereby authorize the above name to operate and store the above vehicle for the SUBTOTAL-LABOR $ 150.00
purpose of testing,inspection,repair and delivery,at my own risk.I understand that the SUBTOTAL-PARTS $144.85
above named is not responsible for loss or damage equipment or articles left on or in
vehicles in case of fire.theft,or any cause beyond their control.I understand that if I $�� 79
wish to retain worn and damaged parts that request will be made at the time of ShOp Supply
authorization or repairs.I understand that rivo(2)days after notice of completion of Envi�Oment8l Fee $5.00
services rendered,that a storage charge of not more than_$per day,will be charged
unless othervvise agreed to in writing.ALL ACCOUNTS ARE PAID BY THE 10TH OF THE SUBTOTAL-OTHERS $16.79
MONTH.ALL CUSTOMERS WILL BE CHARGED A 1.75%SERVICE CHARGE pN
ACCOUNTS PAST THE DUE DATE! I
Signature: Date:
UNDER WARRANTY $0.00 TOTAL TAX $���52
DEPOSIT 0.00
NO CHARGE TO THE CUSTOMER $0.00 323.�G
TOTAL SALES $
PAYMENT: TOTAL COLLECTED $0.00
AMOUNT DUE $ 323.16