Affeldt RECElVED
NOTICE OF CLAIM FORM to t�e City of Saint Pau�, Min�Yo� �014
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall causeltp��p�s���
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,p[ace,and
circumstances thereof,and the amouvtt of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each questioa 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 explain 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 OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name�/'�' O� I�IY\J Middle Initial ✓ Last Name�>{��'�qi��
Company or Business Name��/I�VIN �IQQ`�1 l 1 r�.�{�/
Are You an Insurance Company? Yes/ o f Yes, Claim Number?
Street Address � W . ��1 Y r _
City �l State Zip Code ��� 1
Daytime Phone(� -_��ell Phone )�-�Evening Telephone��)�-�
Date of Accident/Injury or Date Discovered � � "f Time 1�r�_am pm
Please state,in detail, what occuned(happened), and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul c�r its er.:p�o•�ees are invc;v;,�andfar res�onsible�or your ciamages.
a n� -
0
Yl 0 ✓'
�(�I 0
0. YY�
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
�My 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 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 auplicable 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 WILL 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 claims: legible 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 damaged items
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
! '. ' - ':\. . . ,� ':_ '::..�,}--' ' .� '.. .: . .. .:.� . �,'! � . � . .
.. . . . . . . . ... . � .. Y 1 ..
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please comalete 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 calle � n Yes o Unknown (c;�cl ,
If yes, what department or agency?_ ��h''� Case#or report# N
Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility,
c osest andmark,etc. Ple se be as d ailed as possible. If necessary, attach a diagram.
Please indicate the amount y u are s eking in compensa 'on r hat you would like the City to do to resolve this claim
to your satisfaction. �'
° � �'2
o�r�t.w�S No c�o5�
Vehicle Ctaims— lease com lete this sec ion ❑ check box if this section does not a 1
Your Vehicle: Year Make �( Model
License Plate Number, State C or
Registered Owne_
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number tate Color
Driver of Vehicle(City Emp y ' a )
Area Damaged
Iniurv Claims—nlease complete this section �1-Eheck 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 nning 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? Ye No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephoue
❑ Check here if you are attaching more pagcs to this claim form. Number of additional pages
By signing this form,you are stating that all ir�formation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be proeessed.
Submitting a false claim can result in prosecution. Date form was completed �'✓ � �� 1
Print the Name of the Person who Comple this Form:�����lJ� ����'(/�\
Signature of Person Making the Claim:
Revised February 201 1
, � ; , . r .
.
CUSTC�ME #: 2559865 235557 AUtQNa�IOI1O
� � AutoNation Ford White Bear Lake
*INVOICE*
TIMOTHY FREDERICK AFFELDT 1493 EAST COUNTY ROAD E
11110 SWEETWATER PATH WHITE BEAR LAKE, MN 55170
WOODBURY, MN 55442 PAGE 1 PHONE (651� 484-7231
HOME: 612-710-6723 CONT: 612-710-6723
BUS : CELL: SERVICE ADVISOR: 2'727 MERTON AMMERMAN
CO�QR Y�AR MAfCE{MQA�L VIN ` �fCER1SE fs111LEAGE EN�OUT TAG'>
WHITE PLA 13 FORD FUSION 3FA6POK96DR215461 531KTL 19198/19198 ACSCS
DEL DAT£ PROQ. DATE 1NARR. EXP. PROMlSEt3> PO Nb. > `RkTE . PAYMENT IN�f.QATE
14JAN13 D 20 : 00 29APR14 Q CASH 29APR14
R,p. OP�NED '' READY ' OPTIONS: SOLD-STK:DR215461 DLR:44A121
ENG:2 . 0 Liter TRN:A
14 :27 29APR14 18 :47 29APR14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
� R.EPAIR �'�,AT TZRE,�ATCH (FRONT KIGHT, TZRE)CUST4MER H�T;:A PQT HC1LE _
_ V VOID LINE __ _ _ _ _ _
_ _ _ _ _ _
__ __ _ _ _ _ _ _ _ _
33D1 �FQ fl.;DO O .,QO
PARTS : 0 . 00 LABOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE A: 0 . 00
,`;, , � �9198 !T�RE<
, , , , INSTALLED NEW TIRE.
„', , ,DOT: A31847RB4713
****************************************************
_ ___ _ _ _ _ _ _
__ ___ _ _._ _ _
B MUL'��-PQ�NT INSp�'CT�ON
MULTI-A CUSTOMER REQUESTED TO HAVE A MULTI POINT
_ _ _ _ _ __ _ __ _
_ _ _ _ __ __ _ __ __ _ _ _ _ _ _
>INSP��TIC1I�t PEFtFCJRMED THI$ ZT3SZT
3301 CFQ _ __ _ _ 0 . 00 0 . 00
_ _ _ _ _ _ _ _ _ _ __ __ __ _ _
Q99P NIULTT-PC�INT INv�PECT�flN
3301 CFQ 0 . 00 0 . 00
_ _ _ ___ _ __ __
PARTS: 0.00 LAB�R; '' a. 0� OTHERi' `` O.O:D TOTAL; LINE B: ? 4.:Q0
, , , , 19198 MPI PERFORMED MPI _ _ _ _ _ _
*:**�r**:*�***�,�**>*********�*�*�*�*******�**�*****�****
C** MOUNT AND BALANCE l TIRE-RETIGHTEN AFTERMARKET WHEELS AFTER 100
_ __ __ _ _ _ _ _ _
MILES !'
MBVl MOUNT AND BALANCE 1 TIRE-RETIGHTEN
_ _ _ _ _ _ _. _ _ __ ,
_ _ _ _ _ _ _ _ __ __ _
_ _ _ _._ _ _ _ _ _ _ _ _ _ _ __ __ _
AFTERMARKET WHEELS AFTER 100 MI��S
_ 3301 CFQ _ _ _ 17 . 50 17 . 50
_ __ _ _ _
1 '>.9002�1549!059*�OOQ 235/40R3.9'; ' 279.'95 .'279.95 279.;95
_. ,
1 DISP*FEE* TIRE DISPOSAL 2 . 50 2 . 50 2 . 50
'PARTS;;: i,2 82 .4 5 LABOR: ': 17.50 OTH'ER:' '' 0.0 0 mOTAL' LIN� C: ' '2�9 .;9 5
, , , , 19198 NEW TIRE. MOUNTED AND BALANCED NEW TIRE.
***�r*�***�*�***�*��r**�*****�*��**:*�*�r***�**�r*�*�****
D** ENTER DOT CODES l . 2 . 3 . 4 .
DO`�S 'A3I847RB4713 >
_ _ 3301 CFQ` _ ; _ _ 0 . 00 0 . 00
PARTS': 0 .0 0 LiABI�R; ' Q.Q 0 �TI�ER: 0.0 4 TOTAL! LINE D: I 4.;0 0
, , , , 19198 DOT CODE DOT: A31847RB4713
*****�r*********:��***�*********����**,�****�*****;<*�***
E** FOB IS INOP
SERVICE HOURS aUICKLANE HOURS STATEMENT OF DISCLAIMER b�$CRlPT10N T4TAES
The factory warranty constitutes all of the LABOR AMOUNT
MON. -THUR. MON.-THUR. warrarrties with respect to the sale of this
7:00 A.M. -7:00 P.M. 7:00 A.M. -7:00 P.M. item\items. The Seller hereby expressly pARTS AMOUNT
FRIDAY FRIDAY disclaims all warranties either express or
implied, including any implied warrenty of GAS,OIL,LUBE
7:00 A.M. -6:00 P.M. 7:00 A.M. - 6:00 P.M. merchantability or fitness for a particular
SATURDAY purpose.Seller neither assumes nor authorizes SUBLET AMOUNT
7:00 A.M. -4'00 P.M. any other person to assume for it any liability MISC.CHARGES
• in connection with the sale of this item/items.
ALL PARTS NEW ORIGINAL EQUIPMENT TOTAL CHARGES
BODY SHOP HOURS PARTS HOURS UNLESSOTHERWISESPECIFIED LESSINSURANCE
MON. -FRI. MON.-FRI. u-usEO R-REBUILT
7:30 A.M. -6:00 P.M. 7:00 A.M. -6:00 P.M. v-aeCYC�ED C-RECONDITIONED SALES TAX
SATURDAY CUSTpMER SIGNATURE PLEASE PAY
7:30 A.M. -4:00 P.M. X ! THIS AMOUNT
CUSTOMER COPY ��uC��G�Qi Q�GG'
�
CUSTOMEP #: 2559865 235557 AutoNationO.
, *INVOICE* AutoNation Ford White Bear Lake
TIMOTHY FREDERICK AFFELDT 1493 EAST COUNTY ROAD E
11110 SWEETWATER PATH WHITE BEAR LAKE, MN 55110
WOODBURY, MN 55442 PAGE 2 PHONE (651) 484-7231
HOME: 612-710-6723 CONT: 612-710-6723
BUS : CELL: SERVICE ADVISOR: 2727 MERTON AMMERMAN
>� COLQR YEAR : ' M�kI�ElMQA�L VIN ' '' �1GENSE '' M11,ERG�it�lf'>L7UT TRG >• '
WHITE PLA 13 FORD FUSION 3FA6POK96DR215461 531KTL 19198/19198 ACSCS
DEL DA7£ PROD.I)ATE V11AftR.FJ�P, f�ROMISED PO N�. RATE : PAYMENT> IN1l. IJA7E
14JAN13 D 20 : 00 29APR14 Q CASH 29APR14
R.O. OPENE'a ! REApY ' '' OPTIONS: SOLD-STK:DR215461 DLR:44A121
ENG:2 . 0 Liter TRN:A
14 : 27 29APR14 18 :47 29APR14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
CAUSE c! REPv
- _ _ _ _ _ _ _
ADD ADD ON LINE FOR ADDITIONAL REPAIR WAS
_ ___ ____ _ _... ___ __ _ _ __ _ __ _ _
_ _ __ _ _ _ _ _ ___ _ __ _ _ _ _ _ __ _ _ __ _ _ _ _ _ __
_ _ _ _ _ _ .._ _ _ __ _ _ _
>AUTHQRI�ED
_ 3301 WFQ _ _ (N/C)
15 6�7I7 PR'I'S K�- � SAT�.ERY :REPLA.CE
_ _ _ _ __> _ _._ _ _ _ _ _
(CR2025/CR2032) - L
__
' 3301 WFQ (Nfe}
1 ECR*2025* X- _ �N/C)
1 ECR*20�5* �£- (NJC)
_ FC: L23 42 _ _ _ _ _
___ ___ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ __ _ __ __ _ _
PART�- I Z�K6�1 _ _
COUNT.
CT:;ATM TYPE:', _
AUTH CODE:
Q�21Q3''.
___ ___ .
PARTS : 0 . 00 LABOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE E: 0 . 00
_ ___ __ ___ ___ _ _ _ . _ __ ___ _ _ _ _ _ ___._ _
,,, , , 19198 15I�601 ��42�� VERIFIED KEY �'�B WAS`` INO�. RAN' C?ASSS NO SSM dR
_ _ _ -,.
, , , ,TSB. INSPECTED FOUND BATTERIES WERE DEAD. REMOVED AND REPLACED
. , . ,BA'�'I'ERZES. VERIFI�D NEW $ATTERIES 'WQRK. KEY FOB WORK�.
****************************************************
_ _ _ _ __ _ _ ___ _ _
�USTOMER P;AY SHQP SL7QPLIES FOR REP�.TR 'C�RT3��Z � ,1�
�
_ _ . _ _ __ _
____ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ ___
_ _ _ _ ___ _ _ _ _ _ ___ _ _
___ _._ _ __ __ _ __ _ _ _ _ __ _ _ _ _
_ ,
> �
_ __. _ _ _ _ _ _
SERVICE HOURS QUICKLANE HOURS STATEMENT OF DISCLAIMER E7E$CRIP1'IG1N I TOTA�S
The factory warrantv constitutes all of the �ABOR AMOUNT ']
MON.-THUR. MON. -THUR. warranties with respect to the sa�e of this
7:00 A.M. -7:00 P.M. 7:00 A.M. - 7:00 P.M. item\items. The Seller hereby expressly pARTS AMOUNT 4 5
FRIDAY FRIDAY disclaims all warranties either express or
implied, including any implied warranty of GAS,OIL,LUBE Q . Q Q
7:00 A.M. -6:00 P.M. 7:00 A.M. -6:00 P.M. merchantability or fitness for a particular
SATURDAY purpose.Seller neither assumes nor authorizes SUBLET AMOUNT �
7:00 A.M. -4:00 P.M. any other person to assume for it any liability MISC.CHARGES 3 . 15
in connection with the sale of this item/items.
BODY SHOP HOURS PARTS HOURS ALL PARTS NEW ORIGINAL EQUIPMENT TOTAL CHARGES Q ,
UNLESS OTHERWISE SPECIFIED LESS INSURANCE O . O O
MON. - FRI. MON. -FRi. u-use� R-REBUILT
7:30 A.M. -6:00 P.M. 7:00 A.M. - 6:00 P.M. Y-RECVC�EO C-RECONDITIONEO SALES TAX
SATURDAY CUSTOMER SIGNATURE PLEASE PAY
7:30 A.M. -4:00 P.M. X THIS AMOUNT � 2 ;
CUSTOMER COPY �ri,u�j�(� Zla�GI
)
6�6?47�J$BEPR LPKE
ANF6EASHGWNTV�11�
�q93 �PVF',.
�{ITE86�_4ii4-,L�1�OH
� jpPrPfl�� `
AU ,1's5
{tz i
�p: F1�1`'
ler;, �
Sa �
`�:��,�,�,X'�`�kX'�2� Erts���' '���al
�� 1s�.q��.2� .
�q,rty;ih �,pr�ode�5�1113
lnu��.�"3� 9atchp:11°-�i
��;�nline �
�p� >.s5��? ^f�"•2� '�
���5[ktt 11�.�_.., � �C�. ����
i0ta���
C.fllo�ef
(�.ony