Cherney REC�IV��
NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso�Y 02 2014
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be�1,s��lted tdlta���yK
governing body of the municipality 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 egplain 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 O'�'HER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
.J—
First Name � �-{('j�� Middle Initial � Last Name ��1(=�1��/
Company or Business Name IlJ�/�
--_ ......�.� _ _ _ -- - -
Are You an Insurance Company? Yes/ o If Yes,Claim Number?
Street Address 7js�j� (�(.�1J L�JI�E
City �St�'111�G5 State ����SO� Zip Code SSO 3 3
Daytime Phone(C�l )�z'- �I�I Cell Phone(�$I )�q-Q�� Evening Telephone(�) )�R -QS4�F
Date of Accident/Injury or Date Discovered [�I�p�ll. ZDIU Time 5�� 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 your damages. T�2AVEU�G
SputTN P�xx,t Ul� b�U S�Ei.�t►UG P-J�"�x.�C, Ct�2�x 1.C�D �Fh2.�S 1JC)�11--t o�r T�-1t
Ta�-I �14Si T3c9u�1� '�1� 1?F1�P t� cT LA�.vC � lJ �� t�P T E � �N
J � F' t U l T'�l(�L t s� 1'l� � t�l3�l.�{-(.ifT ..[tti�lN/l�i)l1i'�C��.
�.E =2E 1�-1E " t u.-� N,4 ��
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.�?�N _�?i7�I ►�Ul l 1.�"S 0� �l`�"C�I�K
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
�NIy 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 praper�
-----� — -----
------ __.
"-- Q Other type o�propert,y�amage—please specify
❑ Other type of injury—please specify
In order to process your claim you 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 WII,L 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 claixns: legibTe 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 datnaged itexns
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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims–nlease comulete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes � 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,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. 5►J(�Z��/�iJC
�c,�1�-4(�oct�(� �rv X 2���5�wt. .1`�c�l oN S�(�.�r
Please indicate the amount you are seeldng in compensation or what you would like the City to do to resolve this claim
to your satisfaction�259 �SO
Vehicle Claims—please complete this section _ � Pc hnx if thir�A�+��r�_�-��-�---a-,�-�� _
YourYhicTe: �ear Zpp(o Make Q,��� � Model /�(.�
�µ,v�,0 O .License Plate Number 4� Ct.0� State ►'►ti�-Color S L W�c
Registered Owner"j1�'C96W1'S ;S�x�CT CHC'�YZrJ�
Driver of Vehicle "�l-+pKl�PrS �', CN�`f�y!�
Area Damaged�j"L�UC12S S I O E �20�T Tt 2E
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 applv
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 Ernptoyer:
Address Telephone
�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 information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processec�
Submitting a false claim can result in prosecution. Date form was completed �/�,lL ?�1�-I
Print the Name of the Person who Compl t d 's m: �Ht:d'(AA'S � Ct-EC c�l,��
Signature of Person Making the Claim:
Revised February 2011
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T 1 R E . �������
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WARRANTY: �;ILEAGE— 6�,���► 5EE REVERSE SIDE FOR WARRHt�1T P` UE s AILS
CDMMEh1T: ROLT �'ATTERiV: 5—i l�
CO�IMENT: INFLATION F:38 P.:4�
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CD�iMEhaT: Tir�e in tr,t_�nk is beir�g r�eplaced, �oLCte Ieft lide
C01�1+1EIVT: #*#�udi stip�_tlate' s if .?,l��s or� less any tire can k�e r���pl��ed �•�ith ��me si�
COMMENT: e/br,and
CDI�hIENT: **#Lf is the :par�e
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BE,666 hJF,t�I 1 L i FET I i+7E ROTAT I C1ta1 L I FET I 1+1E RE�'A I RS I��1�_LUDED . ;�� _�l .�0
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Since yo�� have p�.ir=chase� fe��t� than four-� tir~e= tor� wheels} , we will moustit the ne�� +ir�es on the
r�ear� of yaur vehicle for� t�est safety and handling.
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DOWNTOWN TIRE &AUTO INC.
320 VERMILLION STREET
HASTINGS MN 55033
(651)437-6400
OPEN MON. THRU FRI. 7AM-5PM
24 MONTH/24,000 MILE NATIONWIDE WARRANTY
www.downtowntireandauto.com
3/21/2014 3:37 PM page 1
Repair Order#43181
CHERNEY, TOM Cell Number : 651-999-9644
3532 GRETEN LN
HASTINGS MN 55033
Vehicle : 2006 Audi A6 3.2 L 3123 CC V6 DOHC 24 Valve Tag/State : 041 CUZ/MN
VtN : WAUDG74F56N053029 Last Mileage : 126615
Created : 3/20/2014 2:59:26 PM Odometer In : 146512
Srv Writer: KW Odometer Out: 146512
Labor/Notes
Qty Code/Tech` Reference Description Unit Price Price
3 TK" MAB MOUNT AND BALANCE $20.00 $60.00
Parts
Qty Code/Tech' Reference Descnption Condition Unit Pnce Price
3 — 03522260000 245/40R18"H"CONTI PRO CONTACT BLK $258.34 $775.02
AFUY PXH6 1613.
AFUY PXH6 4313 x2
3 JUNK TIRE DISPOSAL a2.50 $7.50
3 WW WHEEL WEIGHTS $1.00 $3.00
2 ECH 920261 TPMS SENSOR KIT $5.30 $10.60
Labor ....................................................... $60.00
Parts ....................................................... $785.62
Sublet/Misc. ....................................................... $0.00
ShopSupplies ....................................................... $0.00
Charges ....................................................... $10.50
Sales Tax Tax @$788.62*7.1250% $56.19
Repair Total $912.31
ech e�t cation
TK
I hereby authorize the repair work herein set forth to be done along with the necessary material and
agree that you are not responsible for loss or damage to vehicle or articles left in vehicle in case of fire,
theft or any other cause beyond your control. I hereby grant you and/or your employees permission to
operate the vehicle herein described on streets, highways or elsewhere for the purpose of tesfing andlor
Inspection. An express garagekeeper's lien is hereby acknowledged on above vehicle to secure the
amount or repairs thereto. All Vehicles left over 48 hrs. after repairs are completed WILL INCUR A
$5.00 PER DAY STORAGE FEE. All repairs cover by a 24 month or 24,000 mile nationwide warranty.
'* NOTE "`* WHEEL LUG NUTS NEED TO BE RETORQUED AFTER 100 MILES IF REMOVED FOR
ANY REPAIRS.
Customer Signature
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� r VEHICLE IDENTtFICATIQN NUMBER � YEAR MAKE MOOEUBODY TITLE NUMBER ��-
' WAUDG74F56N053[I29 06 AUDI 4'A 'It63 H225�Y399
� DATE ISSUED ODOMETER TAX BASE CODE PLATE NUMBER CENTRAL OFFICE USE ONLY
�� 08113l09 58568 044690 �9 D41CUZ �s-
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�� FIRST SECURED PARTY DOB OWNER �'
:� 06/24/09 D3041 CHERNEY THOMAS J4HN ' �
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� PENTAGON FCl! _
��� 3532 GRETEN LN � ,
�, P0 B-0X 1423 HASTINGS MN 55Q33-4142 �
�� ALEXANDRIA VA 22313-2032 �
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ToTa� �zENS 1 a11�I111�iIM�INI�INIII� AI��I�I�I�I�I�N�INIIII�INIlN�NI�
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� FEOERAL AND STATE tAWS REaWRE THAT YOU S7ATE THE MI{.FAGE IN CONNECTION WITH THE TRANSFER OF OWNERSHIP.�IINNES97A lAW REQUIRES THAT YOU MAKE A
� DISCLOSURE ABOUT DAMAGE TO THE VEHICLE. A FALSE OR FRAUDULENT S7ATEMENT OP PURCHASE BY ANY PERSON IS A GROSS MkSDEMEANOR OR FELONY. �'�y-
_�`}�ODOMETER DISCLQSURE STATEMENT.I(WE)CERTIFY THAT THE ODOMETER NOW � ❑IS ACTUAL MILEAGE . �. �� ��.� ����. � : ` -� �
�����REAOS � :� � � ❑�CEEDS MECNANlCAL LlMITS OF ODOMETER � �
(NO TENTHS)MiLES AND TO THE BEST OF MY p IS NOT ACTUAL MlLEAGE-WARNING ODOMETER DISCREPANCY � ��'��
:KNOW�EOGE THE ODOMETER MILEAGE: . . � � .
DAMAGE�ISCLOSURE STATEMENT. TO THE BEST OFMY KNOWLEDGE,THIS VEHICLE: ❑HAS p F+AS NOT(CHECK ONE)SUSTAINED DAMAGE,EXCLUSIVE OF ANY COSTS TO REPAiR,
��..�REPLACE,OR REINSSAIL A1R BAGS AND:OTHER COMPONENTS 7HAT WERE REPLACED DUE TO DEPI.OYMENT OF AIR BAGS,IN EXCESS OF 70 PERCENT AGTl1AL CASH bALUE. ��.�. �� �
�,9�, ASSIGNMENT:I(WE)CERTIFY THAT THIS VfiHICLE IS FREE FROM ALL SECURITY INTERESTS,WARRANT TITLE,AND ASSIGN THE REGISTRATION TAX AND VEHICLE TO: �
� : �
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r.f{!5. � � � � SELLER�S PRINTEO NAME 5 �� � � DAT£OF SALE � .� �BUYER S PRINFED NAME S) . . .
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SELL'ER�S ADDRESS � DEALER�S LICENSE � BUYER S ADDRESS� � . �� �g �
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��: � � �� � �SELLER�S 51(iNATURE(S� � � � BUYER�S SIGNATURE(S� �. �-
'� APPLIGATIQN FOR TtTLE BY BUYER TRANSFEREE . MUST BE SUBMITTED WITHtN 10 DAYS Please Print �
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` ��BUYERSWlh'c� iAST FIA$ ANDOLE OAIES OF&RTH BUYER'SOWVEft'SLICENSElAIM0ER5
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`�SiftcETAbbRESS �� ��� ��� :�� � - ' CITY COUNSY/CODE � S7ATE Z�PCO�E
.� IS THIS VEHICCE SUBJECT TO SECURITY AGREEMENT(S? ❑NO ❑YES IF YES,COMPLETE SECTION BELOW) �.-
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� FIRSTSECURE�FARiY'$NAfdE(PRINTNN.IE OATEOFSECIMiIiVAOREEMEM ATTAGHCOMP(.ETEDGORMPSZO�7: � .
$TREcTAWRESS . � . . CILY � . . . SUTE � �.ZIPCO�E ..
I(WEj CERTIFY f(WE)AM(AREY OF LEGAL AGE,HAVE PURCHASED THI$VEHICLE SUBJECT TO LIENS SHOW N AND NO OTHERS.1(WE)ATTEST BY THIS TRNJSACTION THAT THIS�VEHICLEiS AMD WIILCONTINUE 70�INSURED.�
_..l. WHILEOPERATEDUP4NTF{�PUBLICaSTREETSANDtlIGHWAYSALLOFA7Y��i1R1DEClARAT10NSARETRl1EmIIICQRREG7. . -- � �- � -
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4� VElRCLE.FMUHE TO PRa/IDE REWIREO NFOPoA4TION WV PESIAT W OFIiAL�OF TNE REIX�STE�AC710N.E%CEPT fOFi CERTAIN;LSES PERD.NTTEO BY FEDERAL � �
���.ANOSTAtEUWSPERSOWIL 11&OMIAT�ON GONfNF�O Nl YOUfi APPLMAtiON/MY NOT BE pSCL05ED TO ANYONE WIhK.UT YpUft EXPRESS CONSENT.YW M�Y
:�E7NRE3.4LY CONSENT T�TNE�dSCIOSUHE OF YWR II�ORMATqN BY WRI7tNG 707lIE FqlOYANG ADDRE55�. I
MINNESOTA�EPARTMENT OF PUBUC SAFETY �
��: OR4VER AND VEHICLE SERVICES DIVISION � �
445 MINNESOTA STREET,ST.PAUL,MINNESOTA 55101
ys � (�'�)('�I I��I��II III�I�'I I�l���l"�I I'�I . PHONE 651-Zmndriveinfo om 651-282-6555 � � .
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MZNMESOTA MOTOR VEHICLE RE6ISTRATIQN
SELLER'S NOTICE OF SALE I YR nK n�� viH
INhen you seli this vehicie,you are►esponsible to 8Ie the Informatioa on the baek sida ot this notice wRh the 06 A U D I 4 D A 6 3 YA U D 674 F 5 6 N 0530 29
Deparperent of Publk Safety wlthb�f0 dava.Plesse Rle this infortnation over the intemet at m[�drivei�foam. PLATE • STICKER s TAX EXP
cali 65b284-1234,or complete aU tbe infortnation on this noUce and maii to the address below.Thta not�e is not �y 1 C U Z K32 4 4113 3?b.00 05!31/1 D
requiredifsoldtoalicenseddealer.MinnesotastaWte168A.10 6ROSS VEHICLE YEI6HT/BASE VALUE D44690
� RECORDED OYNER(S)
. ` MINNESOTAOEPARTMENTOFPUBLICSAFETY � CHERNEY THOMAS JOHN �
ORIVER AND VEHICLE SERVICES DIVISION ' ' � . �
445 MINNESOTA STREET,ST.PAUI.MINNESOTA 5510tS168 � �
����������������������� 3532 6RETEN lN
TITLE NUMBER H225�Y399 VIN YAUD674F56N053029 HASTIN6T MN 55033�4142