Thompson ���EivEo
MAY O 1 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne��Y C L E R K
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
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 darit�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 prceess can take up to ten weeks or longer depending on the
nature of your ciaim This form must be signed,and both pages rnmpleted. If sometWng 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 Inirial'� Last Name 1�/1�)1�l1����-,
Company or Business Name N`�
Are You an Insurance Company? Yes/ o Yes,Claim Number?
Street Address '
City W��-i -L� State M I�l, Zip Code�_
Daytime Phone(��- 1►��Cell Phone(_) - Evening Telephone( ) -
Date of Accidenb Injury or Date Discovered��c� � Time l Z'.�L am/ m�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please i dicate why,or how-you
feel the City of Sa,int Paul r its employ . s are involv and/ r responsible for your dama es.�„ +� �1
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Please check the bcftc(es)that'most closely repr�nt ttie teason for complering this form:
❑.My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
L�My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
�7 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 auulicable 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 WII.L NOT be returned and become the property of the City. You aze 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 i�sued and a copy of the impound lot receipt
O Other property damage claims:two repair es mates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs aze 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-please comulete this section
Were there witnesses to the incident? Yes U own (circle)
Provide their name ,addre ses and,tele hone numibers:
� �'�4r1.< � Z 51— - �
Were the police or law enforcement called? Yes No Unlrnown (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.
c osest landmark,etc. Ple e be as detailed as ssible. If nece sary, ttach a diagram. ��P ' ►.V
� Q v', �:.�n►�e,. C. r� � r1� ti irr�ur.j
Please indicate the amount you are seekin in compensation or what you would like the City to do to resolve this claim
to your satisfacaon.
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Vehicle Claims- lease com lete this section ❑check box if this section dces not a 1
Your Vehicle: Year� Make � Modei "�L�
License Plate Number � State tir.�,Co1or�jSgc l�.-� _
Registered Owner 4 r
Driver of Vehicle �''
Area Damaged
City Vehicle: Year e Model
License Plate Number State Color
Driver of Vehicle(Ciry Employee's Name)
Area Damaged
Injnrv Ciaims please comvlete tlus section [S�check box if this section dces not avvlv
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 vou 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: Telephone
Address
❑Check here if you are attacWng more pages to this claun form. Number of additionai pages
By signing this form,you are stating that all infor►nation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be p�tocessed
Submitting a false claim can result in prosecution. Date form was completed�..�Z� ��`�
Print the Name of the Person who Completed this Form:
Signature of Person Maldng the Claim:��LV��r ��--
Revised February 2011
o Pi-p`cE ��,�F *****
� RiCK&ToM's ***** RETAI L INVOI CE
04/29/14 12:23pm
CASHOI 60796
��0��
TIRE & SERVICE �4�2g�1q p4/29/14
1137 South Robert Street
West St.Paul,MN 55118
651-450-0535 01 5 i 2 o i
651-450-0537
C MARY THOMPSON page : 1
Vehicle Information
� License : XXP928
S Make : ACURA
T � Model : TL
� Phone: 651/757-0929 Year : 2005
M Mileage : 107163.0
E Hand Ticket: 60796
R
User ID: KAU
os xousE SALES PURCHASE ORDER N0:
SALES PERSON: �� � � �
� . �
. . � �
• P235/45R17 UNI T-PAW GTZ 1.00 90.00 0.00 0.00 90.00
NST 1.00 0.00 0.00 0.00
TIRE CHANGE - NO CHARGE 0.00 0.00 0.00 0.00
T-TCNC 1.00 0.00
T_B COMPUTER SPIN BALANCE I 1.00 0.00 0.00 0.00
VALVE STEM 0.00 0.00 0.00 0.00
T-VS 1.00 2.00
T-JT TIRE RECYLING FEE 1.00 2.00 0.00 0.00
SS SHOP SUPPLIES
98.56
payment Typ : VISA
�
92.00
Sub Total
6.56
Tax Total
Amount Due 9 8•5 6
I HOMEfOWN TINE&SERhCE ACCOUNTS NECEIVABLE CONDfT10NS
In the event of defautt in payment when due of any indebtedness cre<
TERMS ARE STRICTLY 30 DAYS by acceptance af materials and labor provided by Hometown Tire&Sen
Hometown Tire&Service shall be entitled to interest on any such indeb
ness from the date due at the highest legal rate plus attomey's fees and c
10%RESTOCKING FEE ON ALL RETURN�D ITEMS costs,should Hometown Tire&Service choose to employ an attomey to ca
NO REFUND ON SPECIAL ORDER PARTS OR TIRES ���F���/4�RVICE CHARGE ON�DUE ACC�oR�n�
. • PERCENTAGE OR 18%
Customer Signature X