Getsug � REC;E11���
NOTICE UF CLAIM FORM to the City of Saint Paul, Minne o aY �$ z0�4
�ITY C�L�RK
Mennesnta Stnte Statute 41h.05 stutes thut` ...every penson...who clnims dama�es from ruty municrpr�liry...siu�t!cuuse lo f�e prese�vert tn e
Ruverninx bodv a/�Ihe municipality�lxilhin 180 duys a/1er the rt!leged loss or ir�jury i.�drs<•overed cr nuticr smtir:g the�ime.pluc•e.and
crrcum.rtanc-es rlrererrf,mtd the anu�unl of r,nmpensntion nr otlter relief demarided.'
1'leatie complete this PE�rm in its entiret�� t�y clearly ty�ing or printin�;t�our.sns►vcr to each yuesti�>n. If inore sp.ice iti
needed,attach additiont�l sheet5. Y[ease ni►te that yc►u�vill�ot be c��nEacted by telephoae tu clarify ansn�rti,so provide as
much informattun�is��ecessary to expl�►In your claim,und the amciunt ol'compens.�tion bei«g requ�sted. You H ill recei�e�
written acknowled�ement once��uur form is received. '1'he process can cake up to ten weeks or longer depeodtng un the
nature�tt'your claim. 'I'liis forn�must be tiig��ed,xnd both pages completed. lf si�mething docs not�pply,write`�/A',
SLND COMPLL�I'�ll I�,C)RM ANll O�I'H �R llOCUML+'N'I,S 1'U: CI'I'Y CLEKK,
lS WES'I' KELLUGG BLVD, 31U CI�I'Y H�LL, S�1IN`I' I'AUL, NIN 551�2
First Name_�����" Middle Initial — Last Name �TSI.IL i
Company or Business Name
Are You an Insurancc Company'? Ycs o If Yc;s,Claim Numbcr?
Street Address � 1� Cl�b�-�L.�D �����
City � PAr�I� St�ite�,� Li�Code�l 1�-l�l 1
I?aytime Phonc � 2)�__�Cell Phone(�Z)�-_��Fvcning Tclern<�ne(�)�-��
Date of Accident/Inj��ry or Date Discovered 5�T��- Time ����S am m
Please slate,in detail,what occurred{happened), and why you are submitling a claim. Pleasc indicutc why or how you
feel the City of Saint Pa�31 or iis erY�plo_yees are involved andh�r responsihle for your darnages.
� o �- c� a�
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O D (,u .
w� �-�r-����a ���t � s .
l.'leasc check lhc box(es)lha�most clasely represent the reason for comJ�lcting lhis ('c�rn�:
� My vehicle was damaged in an accidenl � My vchicle was damaged during a coti�
�j My vehicle was damagtd hy a pothoie or condition of the streei ❑ My vehicie was damaged by a plc�w
❑ My vchicic wati wrcmgfully towcd anclJc�r tickctcci � 1 wati injurcd c>n City proEx:rty
❑ Olher type of property damabe–please specify
� Othc,�r type of injury–please�}�ecify
In arder to process your claim��ou need tu include a►pies of all applicable document�ti.
For the claims tyJns list�d belc.�w, ple:�,5e he sure to include lhe documenls indicait�d o��it will delay thc handli���*of
y�ur claim. Documents WILL,_N(_)T be returned and become the property of the City. Y��u are�ncc>uraged to keep a
co�y i'or y�vursc;lf hcfc�re suhmitting y��ur claim l�cirm.
�SProperty damage cI<iims to a vehicle: two estimat�s for the rerairs to your��ehicle iC the dam�age exceeds
�500.00; or the actual bilts and/or receipts far the repairs
O Towing claims: legihic co�ries o1'any ticket issucd an�a copy c�f the imp<�und lot rcceirt
O Olher properly damage cl�ims: two rep�tir e;titim�tl�ti i(�the d�►tt��tge c:xceedti..��500.(x): c�r thc actual bills
and/or receipts f�r the repairs; d�iailed tist of damaged iten�s
O/Tnjury claims: medicll bills,receipts
PS �'hatc�graphs arc always wcicc�mc to document and sup�ort your claim but wi13 nc�t lx;rcturncd.
Pa�e 1 of 2–Please compiete and return bath pa�es of Claim Form
Failure to camplete and ret�crn both pa�es wiil resi�it in dela��in the handiin�af��o«r cial�n.
All Claims—please cotnplete this sect3on /�����t�� �������
Were there wiine.�ses t:o the incident'? ��� No Unknow�i {circle}
Yrovi�ic their namc,s, �d re,�scs ana tclerhone numhc;rs: �o D `���«
U `, �
6!Z- '`t'T� -�l.c�2.. ����
VVere the}�olice or l�w enforcement called? Yc:s N<� Unknown (circic}
IC yes, whal department or a�ency? Case#or reporl#
Whcrc did thc accident c�r injury takc place'? Frc7vicle�tr�et address,cross �lrect,intersec�ic�n, nam4 af'p�rk r�r('acility,
closest lancimark,etc. Please tx;ati delailed as pc.�ssible_ If�nct�ssary,attach a diagram. ,���f�I'���T� �s�a•`���"
L:�t��
Please indicate the amount y u are sezking in compensation or what you wauld tike the City to do to resol��e this clairn
tc�your satisfaction,_��_��
�'ehicle Claims— lease com lete t#�ts section ❑ehe�k box if this seceion does nai a 1
Your Vchicle: Year_�O�,��Make �u1LIL Mo�icl o
Licensc Plate Numb�r���5'� Slate Color
Registered C}wner
Driver c�f Vehicle
Area C)amaged �2.0 �'c�� ���,
CiCy Vehicle: Year Make Model
License Plate Nun�t�er State Gc�lor
1?river oJ'Vehicle(C'ity F:mnlc�yec'�Naane)
Area I�amaged
I�ury Cialms—please catnplete thls sertfan ,�.ctr�ck box if thi�sectic�n dcx5 nc�t applv
Haw wcrc yc�u injur�ci?
What part(s}c�f your body w4re ir�jurecl?
Have yau 4ought ineclicll Crcat►�ient? Yes No PlanniEi�to.rieek Trcatment(circle) '
When did yau receivc treatmenY? {provide datc(s))
Name vf Medical Prc�vid�r(s);
Address Telephane
Did you miss work as a result of your injury'? Yes No
Wh�n did you miss wc7rk? (Pr��vide date(s)}
Nam�of yac�r Employer: _
Address Telephone
�I Check I�ere if you are attaching more pages to this cl�im forni. Nurt�ber of aciclitional �ages�.
By si�ning this farm,ynu are statirtg that all in�'i�rntation yote ltave�rovr.ded rs trr�e and currect to tlte best
o f yvur knoxvledge. Unsign�d fornas wil�not be processetl.
Srebmittiri�a fal..se clairn can result irt prnsecution, Date f�rm �tias complet�d � 2o I�_
Print the Name of the Perst�n who Ccfmpleted thls rnrn�: � G�TSu
Signature of Person�VIaking the Claitn:
Revised rebn�ary 2U I 1
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���� How did we do? Please, complete the survey at
www.ntbcares.com Use password�6sis9sl 00005
> TIR68•SERYICE•BRAKES•BATTERIES
NIN NATL TIRE & BAT ## 875 * FINAL BILL -INVOICE** Page 1
2185 FORD PKWY Invoice# 76518951 - RI
ST PAUL MN 55116-1816 Order Num 50798212 - WI
(651) 690-5007 Date/Time In. . . . . . . . 05/05/14 06 : 13 : 13
Date/Time Promised. . 05/05/14 13 : 02 : 31
/�
2013 BUICK VERANO
�*� �'�J Tag: 129KSE St: MN Mileage: 5121
� � � � V� I ' � � I �� Engine: VIN# 1G4PS5SK1D4214476
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Customer: 26380133 PO#: Ship To:
GETSUG, RAY
2090 HIGHLAND PARKWAY
ST PAUL MN 55116
Opening Salesperson 12965207 Home# 651-690-2974 Work# 612-309-8665
Email :
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Item Number Item Description Qty Price Each Extended
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XPTR CONTINENTAL PROCONTACT 1 228 . 54 228 . 54
DOT # :A3X6 BNH 1214 1
235 /45 18 94H
New
TDC Tire Disposal Charge 1 3 . 00 3 . 00
New
WAP PROGRAM WHEEL ALIGNMENT 1
12965205 JOHNSON, JEREMIAH
NTBCARD NTB Card 249 .20-
CARD NUMBER 8686 APPR 005571
IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK
TO OUR STORE M�NAGER, WILLIAM PUNCHES
AT (651) 690-5007
Special Credit : ^^w ^ w
.
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