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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� c '� �'E �'�u 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 ���.# ����� � , ��� � `.���y,,,'s���,�' 2 �,� � yy ,�. - �.�.� ��,:._. 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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 ------------------------------------------------------------------------------- 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 : ------------------------------------------------------------------------------- Item Number Item Description Qty Price Each Extended ------------------------------------------------------------------------------- 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 . �3 m �Hn o�•�no w on��w ntro aro a no�cr*a yro�K o rtHN�z cn w H �yz yny�H �n o rnmNmz ' �tii �• x n�u,on�ro��•oa�oaM�-m�nMo�d���on��wHo ro n �ny onmo� c-r v, tnHt-'HH m?d W H Nrn pN 'L7ro�r*7�'�G r �nP�Nrn�NA.NnNG� N • H [�7 nW crNW crNnnC o � r-� m � H fx� p C]�t1 tD tn N P.rT n fD tD N• �SU tn N•N• p(D n n n c*io x r-i C� O W �'p N A.�O O n o Kf�n Ri� H t�+iZ ����b'���NWO"�G���N��aNfaiNN�•r�,�+rod�7�s'�'7�>wzty�J t�-� aN �HN ~�Air�*N �t N ot�-�OCz � �H ro�WNnC]Z�'C c*�•p o u,c-rpn�r m mrrN•ts' rn;o p �p. �roi--� •• ,A � x n ro n�tn ay wwo��rn,-.o� �•aam � E �'nw� � ro wcr o r• o� x�� cn d3• z u u � o c�wnturnw�rn�n wE o wo cow�•ama�ro3u� � o omn Gax�•• •• o o z x � �p na� o�oM �n�op ��aanwrtc�� rta�oy �c �* �•� ��•• N o ro k� �f O O tr n• n W N• � cD r•ri cY R. 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