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Campbell (2) RECEIUED APR � 0 2014 NOTIC� OF CLAIM I+'ORM to the City of Saint Paul, Minn�s�� CLERK Mi�nrrsotu State Stutute 466.05 stnte.r Jhat "...every persnn...wlu�rinims da�nn�,�es./'rrnn nny nninicipnlity....clinll cnu.ce!o t�e��re.sented tu rhe ,�ni�erning l�uc(y q��tl�e nr��r�ie.�ipality widii�t I80 duys nfter d�e c�/le�er!/nss or injury is discovered a notic•e stnti�rg t/re lime,plare,curd circwnstunces tl�ereof,crnd dte amotuu of compensation or nther relief denrnnded." 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 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 dependinb 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 DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 ��} c�,� n / First Name � � J ' �n C� Middle Initial Last Name l.� � � Company or Business Name � Are You an Insurance Company? Yes� If Yes, Claim Number? �-�' Street Address (�� l ��e� �� City ��" �GW � State ��6�5� ZipCode ��0�- Daytime Phone (��J )�-_��Cell Phone ((�_)��-`�GD 1`6 Evening Telephone(�O�D ��(g Date of Accident/Injury or Date Discovered Time� :0�am/� 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 our damages. � 0. -� v��i n ' d1,U A T u1 �'�1 .- d( C� 11�'� Q��r�Z—�" S tc,5' c N `}� �t��( L C �' � ��•_ � a , �!L �` � � � d�' � ' e_ � � � �, � ( � � , • . „�- OU�`V� �e � q�� p�E�a.d +�y cs,2,. cQlLe� u� 5�ct¢., fk5�5 � tv � � a.�J -1�¢._ Ple s c"�ec`k�h bUx(es)`t�it�most t;losely represent the reason for completing this form:�v� �� ' �v K- � ---- ❑ 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 0 I was in�}ured on City prope 6`�� r �Other type of property damage-please specify ad a hv �'+J��.2 z� �'►� �� 1 Other type of injury-please specify f C cI �2 huel �llc1!'IL � �t, t�„ �.�,.e w cc� l f I�P<tk('a�q�'e---• `r•`�- n order to process your claim �ou 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 lctual bills and/or receipts for the repairs C� � Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt �,�v `r��e �O Other property damage claims: two repair esti�nates if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs; detailed]ist of damaged items (`�� .O Injury claims: medical bills, receipts �Jt� O Photographs are always welcome to document and support your claim but will not be retumed. �j L 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—please complete this section --=- Were there witnesses to the incident? Yes No Unknow (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes o Unknown (circle) If yes, what department or agency? Case#or report# Where did the accident or injury [ake place'? Provide street address,cross street, intersection, name of park or facility, clo�est landmark, etc. Please be as detailed as ossible. If necessary, attach a diagram. � i �+ a • .� t �c; 2� S ur Si(�2 d �� f f`C E�, Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. y , d � �� i�.�--�`"� t ."�'\f�_ Vehicle Claims—please complete this section �Check box if this section does not a�iv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Injurv Claims—alease complete this section "�check box if this tiection doe� not�ply How were you injured? What part(s)ot'your body were injured? �lave 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)) ----f`dame vf-YottrETrr�}rrYer: -- —_ __ -- _ __ ---— — —- - - - Address Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pages� I3y signing tliis form,you are stating tltat ull information yozc liave provided is true and correct to tlze best of your knowledge. Unsigned forms will not be processed. Secbmitting a false claim carc resiclt in prosecution. Date f'orm was completed �' ��/� I � 1 _ 1 Print the Name of the Person who Completed t�'�For : � �� /1'� V1� Signature of Person Making the Claim: � Revitied February 201 I o p��E �� RicK&TOM's�F ***** RETAIL INVOICE ***** ��'"O�� 04/25/14 3:51pm CASHOI 60743 1 TIRE & SERVICE ' 1137 South Robert Street 04/25/14 04/25/14 West St.Paul,MN 55118 651-450-0535 651-450-0537 C CHRISTINE CAMPBELL O1 51153 U Page : 1 Vehicle Information S License : 997-GZX T � Make : SATURN � Phone: 651/210-0618 Model : ASTRA M Year : 2oos E Mileage : 56928.0 R Hand Ticket: 60743 __ User ID: KPrU- _ _ ._,__ ...�_._ _____._ _� _ -__. ___ SALES PERSON: 05 xousE SALES PURCHASE ORDER N0: � . � � � ! � •• � � NST P205/55R16 GDY EAGLE LS RF 1.00 95.00 0.00 0.00 95.00 T-TCNC TIRE CHANGE - NO CHARGE 1.00 0.00 0.00 0.00 0.00 T-g COMPUTER SPIN BALANCE 1.00 9.99 0.00 0.00 9.99 T-VS VALVE STEM 1.00 0.00 0.00 0.00 0.00 T-JT TIRE RECYLING FEE 1.00 3.49 0.00 0.00 3.49 SS SHOP SUPPLIES 1.00 2.00 0.00 0.00 2.00 Payment Type VISA 117.39 I 110.48 i Sub Total 6.91 Tax Total Amount Due 117.3 9 HOMETOWN TIRE&SERVICE ACCOUHTS RECEIVABLE CONDITIONS In the event of defautt in payment when due of any indebtedness created TERMS ARE STRICTLY 30 DAYS by acceptance of materials and labor provided by Hometown Tire&Service, 1�%RESTOCKING FEE ON ALL RETURNED ITEMS Hometown Tire&Service shall be entitled to interest on any such indebted- ness from the date due at the highest legal rate plus attomey's fees and court NO REFUND ON SPECIAL ORDER PARTS OR TIRES costs;should Hometown Tire&Service choose ta employ an attomey to collect any such indebtedness after default. TERMS NET tOTH PROX.-MONTHLY RATE OF 1-1/4 SERVICE CHARGE ON PAST DUE ACCOUNTS OR AN ANNUAL _ , . • • ' PERCENTAGE OR 18% � Customer Signature X .PLqCE `� �ORiCK&Torn's�F ***** RETAIL INVOICE ***** 02/25/14 6:45pm CASHOI 59575 �� TIRE & SERVICE ' � 1137 South Robert Street o 2/2 s/i 4 o z/z s/i 4 West St.Paul,MN 55118 651-450-0535 � 651-450-0537 C CHRISTINE CAMPBELL O1 50167 U Page : 1 S Vehicle Information T , License : 997-GZX Make : SATURN � Phone: 651/210-0618 Model : ASTRA M � Year : 2008 E Mileage : 55205.0 R Hand Ticket: 59575 Us e r I T5"`�t'AU""'°__``�= ��- SALES PERSON: os xousE SALES PURCHASE ORDER N0: � , � . . � ! � .. � 1 1 NST P205/55R16 GDY EAGLE LS 4.00 95.00 0.00 0.00 380.00 T-TCNC TIRE CHANGE - NO CHARGE 4.00 0.00 0.00 0.00 0.00 T-B COMPUTER SPIN BALANCE 4.00 9.99 0.00 0.00 39.96 T-VS VALVE STEM 4 .00 0.00 0.00 0.00 0.00 T-JT TIRE RECYLING FEE 4.00 3.49 0.00 0.00 13 .96 M-OFL OIL FILTER AND LUBE 1.00 24.95 0.00 0.00 24.95 M-FD FILTER DISPOSAL AND SHOP SUPPLIES 1.00 3.00 0.00 0.00 3.00 L CHECK BRAKF`$ 40 TO 50% LEFT 1.00 0.00 0.00 0.00 0.00 L DOES NEED TRANNY F'LUSH 109.90 1.00 0.00 0.00 0.00 0.•00 Payment Type: VISA 490.94 Sub Totai 4 61.s� Tax Total 2 9.o� � Amount Due 490.94 HOMETOWN TIRE&SERVICE ACCOUNTS RECEIVABLE CONDITIONS In the event of defautt in payment when due of any indebtedness created TERMS ARE STRICTLY 30 DAYS by acceptance of materials and labor provided by Hometown Tire&Service, 10%RESTOCKING FEE ON ALL RETURNED I1�EMS Hometown Tire&Service shali be entitled to interest on any such indebted- ness from the date due at the highest legal rate plus attorney's fees and court NO REFUND ON SPECIAL ORDER PARTS OR IRES �osts,should Hometown Tire&Service choose to empioy an attorney to collect any such indebtedness after defautt. TERMS NET 10TH PROX.-MONTHLY � � RATE OF 1-1/4 SENVICE CHARGE ON PAST DUE ACCOUNTS OR AN ANNUAL _ , . • • • PERCENTAGE OR 18% Customer Signature X I