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Howard REC�IVED . MAY 05 2�14 NOTI CE OF CLAI M FORM to the City of Saint Pau��I�fi6�K M i nnesota State Statute 466.05 states that��e�ery person: who d ai ms damages from any muni a pal ityC�al I cause to be presented to the gova�ning bodyof themuniapalirywithin 180 daysafter thealleged lossor injury isdisoovered a noticestating thetime,place,and a rarr�stanoes thaeof,and the amount aF oompensation or otha rel i ef demanded.^ Pleasecompletethisform in itsentirety by clearly typing or printing your answer to each question. If morespaceis needed,attach additional sheets. Please notethat you will not be oontacted by telephoneto darify ans�vers,so provide as much information asnecessary to explain your daim,and theamount of compensation being requested. You will receivea written adcnowledgement onceyour form isreceived. Theprocesscan takeup toten weeksor longer depending on the natureof your daim. Thisform must besgned,and both pagescompleted. If something dcesnot apply,write�1/A�i SEND COM PL ETED FORM AND OTHER DOCUM ENTS TO: CI TY CL ERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAI NT PAUL, M N 55102 First Name �f�V� Middle Initial I\ Last Name 11bW ��1� Company or Busi ness Name Are You an I nsuraix�Company? Yes� I f Yes, CI ai m Number? Stre�Address ( y 3 I�IJC.J,I��/ ST Ci ty S� ��1 t..l C. St�e /"�N Zi p Code S S�d fo Dayti me Phone(��)�D-S�5 Cel I Pfione(� - Eveni ng Tel ephone(� - DateofAccident/ InjuryorDateDiscovered I1t[S �P� 2� ���y Time �-o� �/pm PI ease sta�e, i n detai I,what occurred(happeried),and why you are submitti ng a cl ai m. PI ease i ndi cate why or how you feel the Ci of Sai r�t Paul or its empl o ees ae i nvol ved arxi/or respon 'bl e for your darr�ages. �i 5 � n� ,(�i }- n <el�o b�ok�n -I'o L g etd ` � 30 ' ti n h' a c In a a n � �e 56 �l 4 � � i►�► rlsr.a! ` 5 4 c U,ct� � a � aaoi �c z� � � a%� �t Pl�se c�eck the box(es)thaR most dosely re�xes�t the reason for compl�ing this form: - My vehi cl e was darr�aged i n an acci dent - M y vehi cl e was damaged duri ng a tow �'M y vehi cle was darr�aged by a pothol e or conditi on of the street � M y vehi d e was darr�by a pl ow -' M y vehi cl e was wrongful I y towed and/or ti ckE#ed = I was i nj ured on G ty property � Other type of property darriaye�-�pl�e spea fy ` Other type of i nj ury �please speafy In order to prooe5syour daim vou need to indudecopiesof all aqplicabledocuments. For the d ai ms types I i sted bel ow, pl�ase be sure to i nd ude the documents i ndi cated or it wi I I del ay the handl i ng of your cl ai m. Documents W I L L NOT be returned and become the property of the Ci ty. You are enoouraged to keep a copy for yourself beFore submitti ng your clai m form. - Property darriage d ai ms to a vehi cl e:two esti rrrates for the repai rs to your vehi cl e i f the ciarr�age exceeds $500.00; or the adual bi I I s arxi/or recei pts for the repai rs � Towi ng cl ai ms: legi bl e copi es of any ti dcEt i�and a copy of the i mpound lot recei pt Other property damage d ai ms:two repai r esti mates i f the damage exceeds$500.00; or the actual bi I I s and/or recei pts for the repai rs; d�ai l ed I i st of daraged iterns - I nj ury dai ms: medi cal bi I I s, reoei pts !7 Photographs are al ways wel come to document and support your d ai m but wi I I not be returned. Page 1 of 2 -Pl�secornpleteand return both pagesof Claim Form Failureto completeand return both pageswill result in delay in thehandling of your daim. All Claims -pleasecompletethissection Were there wi tnesses to the i na dent? Yes No U nknown (ci rd e) Provi de thei r narnes,addr�and tel ephone numbers: Werethe policeor law enforcerr�ent called? Yes No Unknown (cirde) If yes,what department or agency? Case#or report# Whe�-e di d the aocident or i nj ury take pl aoe? Provi de street address,cross stre�, i ntersection, name of park or faci I ity, d osest I andrrrark,�. PI ea9e be�detai l ed as po��l� lf necessary,aktach a di agram. 5�G m a6� PI ease i ndi cate the amount you are seeki ng i n compensaki on or what you woul d I i ke the Ci ty to do to resol ve thi s cl ai m to your sati sfacti on. � ($7. �/7 VehideClaims�fpl�secompletethissection l check box if thissection doesnot applv Your Vehide: Y�r �.00 a Make M� /'► Model Q �J u� L i cense R ate Number G T State�_Col or S� �u— Registered Owner �wt5 4+�A►� Driver of Vehicle �S w AreaDarriaged Ca� ss 2r' W City Vehi cl e: Y�r M ake M odel L i cense PI�te Number State Col or Driver of Vehicle(City Employee�Name) Area Darr�ed Iniury Claims�pleasecompletethissection -- check box if thissectiondoesnot applv How were you i nj ured? What part(s)of your body were i nj ured? Have you sought rnedi cal treatment? Yes No PI anni ng to Seek Tre�atrr�t(ci rd e) When did you reoeivetreatment? (providedate(s)) Nameof Medical Provider(s): Address Tel ephone Di d you mi ss work as a resul t of your i nj ury? Yes No When did you misswork? (providedate(s)) Nameof your Employer: Address T�eP�� �heck hereif you areattaching morepagestothisclaim form. Number of additional pages�. Bysigningthisform, you arestatingthatall information you haveprovided istrueand oorrecttothebest of your knowledge. Unsignedformswill not beprocessed. Submitting a falsedaim can result in prosecution. Datefor ascompleted J '" -7 — �� Print theNameof thePerson whoCompl�ted thisForm: �'`��5 rC ���� Signatureof Person Making theClaim: � Revised February 2011 { � �..., x ��, �� �� r - � � � ii � �. � � � i ,r� T �� �� � �x ��� � �� �� ��4 � `��,.'"� .' � �a .� ,r?* y s ,-. , s�.� � �`� � ' �r ' " a� ��e i ' � ��'�,/� '� � d . . :,< � � i , / i �. , ,:i'� F � �� . ��� a/i1'� 1�. �. .�I' �' ,;'_e , �. � _ �, . � � i a,x,, r^.... .- ;, � ; M illJl -2, ,y ,. � - � ;- ' .c� N�ttifliw�«•:'+�1` � , .� ,.,. ..:' _� . �;, �. " , ..-. ,,x ..,'. 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"i�£e,'> ,u!r'� » . . v �.. f.;� . �� ,�, ��� � �d ��.: � l�y,�h,.; �: /,. \� �.. � � ��.'..4� � • 2� '_..i _.� .\�.` �� �`\ ��.� / ��� y.. .�" , ?L_, i; ��. ,.�.�,.'.6 ` �__J �� f a� A � r €.h� /�,,` �� E ;, ,` .L.---_...��. y, � ��:: �:. sSl �• %" � 'Y / ��� � .% Wg„ � L� / n c � ��� .. �// � i .: ." '. / / /,: ., / �-�-'-',.. .j // � ?� �. �r f� �S � �� ��'kv� � $ �� � � �\� tY� !//��C� � s� r�� � r„ 3: � �! ��� m� // ;yis� ,� '. ,S � ��,,, �i \... '`���� . . `+��"�., , .. . * INVOICE * #328014 TIRES PLUS TIME IN/APT: 1331 W. LARPENTEUR AVENUE DUE TIME: ROSEVILLE, MN 55113 PH. 651-645-5409 WAITING / DROP OFF roseville@knapquist.com www. tirespl�sminn.com -Sold To: ACCOUNT#: 305925 TRAVIS HOWARD 1000 SE 8 ST #204 DATE : 05/O1/14 MINNEAPOLIS, MN 55414 Ph: (612)990-5965 INVOICE #: 328014 Billed By: 3ALE3 2002 MERCURY GRAND MARQUIS LS Salesman : LEON WIL30N 3#:2 Rt: 476BJT Mileage:160821.0 Tx:Y .EX#: Ct:R COD: IWS: VIN#: 2MEFM75WX2X654625 KID#: Parkinq 3pace#: APPT: 05/O1/14 7:00 AM Unit Extended Quantity Product � Size/Description/Mfrt TC MC DP BIN� Price F.E.T. Amount T102 TTP FLAT REPAIR M 2 400-TPP TPP FLAT RSPAIR M N NO CBARGE! . Remove tire/Kheel, Duak Tire in rater tank M Z . and discover leak. Dismount tire from M Z . vheel and cleaa bead as necessary. Boad M Z . patch oa iaside of tire over penetration. M Z . Install nex valne stem and computer M Z . balaace. M 2 . Problem Found Nas M Z . _RIM BBNT M Z . M Z . Circle Which Tire Needs Repair M Z , �+r+t++t+;t���++�t����►�,r�t��t,rt���� M Z . Drin/Front Pass�Front M Z . Driv/Rear Pass�Rear++++ M Z , tt�tf��t+a+rtt+�+t+t�t+t��+�t��+�r M 2 . Tires Plus requires retorquinq of luqs M Z . nuts on alloy rheels rithia 50-100 miles M Z . of any service involviag the removal of M Z . wheels from vehicle, M Z 1.0 OPP ALLOY RIM REPAIR, 16" 1 M C 175.00 175.00 , tft�tt�tttrtt�tf���+t�+f��+�+�a++,rt�,tttrt� ti . . ES! bBON FOR COOLANT FLOSH. Z , +��t����+�t��tt+�t���rt���t+�t�t�r������►�� Z Received By: « Page 1 of 2 » , * ZNVOICE * #328014 TIRES PLUS TIME IN/APT: 1331 W. LARPENTEUR AVENUE DUE TIME: ROSEVILLE, MN 55113 PH. 651-645-5409 WAITING / DROP OFF roseville@knapquist.com www. tirespl�sminn. com -Sold To: ACCOUNT#: 305925 TRAVIS HOWARD 1000 SE 8 ST #204 DATE : 05/O1/14 MINNEAPOLIS, MN 55414 Ph: (612)990-5985 INVOICE #: 328014 Billed By: SALE3 2002 MERCURY GRAND MARQUI3 LS Salesman : LEON WILSON S#:2 Rt: 476BJT Mileage:160821.0 Tx:Y EX#: Ct:R COD: IWS: VIN#: 2MEFM75WX2X654625 KIDN: Parking Space#: APPT: 05/O1/14 7:00 AM Onit Bxtended Quantity Product Y Size/Description/Mfrp TC MC DP BIN# Price F.E.T. Amount Merchandise Services 6 Other F.E.P, Subtotal Sales Tax Rotal 175.00 0.00 0,00 175.00 12.47 187.97 Comments: Terms: P0� D06 DAlB AMT, DUB Misc. Adj. . . . . . . . $ 0.00 Cash or Check �: $ 0.00 Credit Card. . : VI . . $ 187.47 Balance. . . . . C . . . $ 0.00 Received By: « Page 2 of 2 » Started: 04/29/14 3:3'7 PM Promised: 04/30/14 EOD Completed: 05/O1/14 3:07 PM