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Prettyman K�ll.aCl!/ �V N1AY 05 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Mi��slbt�'aLE��4 Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the goveming body of the municipality within 180 days after the alleged toss 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 explain your claim,and the amount of compensallon being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weel�s or longer depending on the nature of your claim. This form must be signed,and both pages completed. If sometlung dces 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��i�v ,�_ Middle Initial Last Name � ��,� Company or Business Name -��v�(X ' Are You an Insurance Company? Yes o If Yes,Cl�,im Number? '"�— Street Address �� 1� City � State Zip Code��/ �O . Daytime Phone( "�--' Cell Phone(��Z)�� T�1GEvening Telephone( �^ Date of Accidend Injury or Date Discovered o'� • Time �� O D 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 andlor responsible for your amages. � dT . / • � r Please check the box(es)that most closely represent the reason far completing this form: ❑ My vehicle was damaged in an acc' ent ❑My vehicle was damaged during a tow �' v ' as ama ed b a othole r condition of the street ❑ My vehicle was damaged by a plow ❑ My vehicle was wrongfully to or ticketed [J I was injured on Ciry 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 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 WILL NOT be retumed and become the property of the City. You are encouraged to keep a copy for yo self before submitting your claim form. �roperty damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds $SOO.t10;or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket fssued 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 andlor 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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims–nlease comnlete this section Were there witnesses to the incident? Yes No Unkno n (circle)� � n O�`�� Prov' their ame , d ses and tele ho umbers: O�� – – Were the police or law enforcement called? Yes �� Unknown (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�o�r fa�i�lit�y,, closest landmark et . Please be as etatled s possi le. If ne sary ttach diagram. ��Z b�OC�� o�- b►�a,v�c��r,2 � �u�e.�a�r� �� -�. ��u � Please indicate the ount you are see 'n compe sation r what u wo ld lik the Ci to do to resolve this claim to your satisfactio `� . '� Y' Vehicle Claims– lease com lete this sec 'on ❑check box if this section dces not a 1 Your Vehicle: Year �017�- Make Model 0 License Plate Numb r S tate till�1 Color Registered Owner 1/� Y'Q- Driver of Vehicle Area Damaged ✓1- �' City ehicle: Year e ' Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims–nlease complete this section �check box if this section does not annlv 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): j Address Telephone Did you miss wark as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone heck here if you are attaching more pages to this claim form. Number of additional pa � 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 processed. Submitting a false claim can result in prosecution. Date form was completed ✓ Print the Name of the Person who C p is Form: � . Signature of Person Making the Claim: Revised February 2011 �� IAT ��o ��.��r.��-i�v �v�r�uE ��r. i_ni;l� �r��::: n�N ��4�f� � � ��t"��p��s www.fiatminneapolis.co��? PH: 952-36,'-44C0 Bl�o�i�� St. L�uis Parl� �x:: ��s,-��o� `„ �"-'"-'—�� YE� FRAMI 105 '�;,-"''S46 !'"`�'4%"�8/14 ��5��5660� 580 � -------- �- __---- ---� — - -- _ - -- ---� ,- ---'—-- ��_� ��., � r � �,��.�:E DRIANNE A PRETTYMAN !g��CEE 40 �fi'S'�o (RED) �.�'�"' 3937 SHORESID� CIR '��'`�'{-"'�'AY'"��0�500 POP �°E�`��1.2 � '--� 14 � AVAGE, MN 55378-5638 _ ___._ _ ._ ----- c , - - -� � --- - _ _----- , �"'�` 3 'C F F A R 5 c T 3 8 3 7 7 8 `` � , .__ -----;— —__ - __� _ _____ __ __ _ _ _ _ .__ _ _ drianne2pretty@gmail .com ` � �- " �4'�28/14 ! a��'�P'�-7406__ _�'6�6�'�E2141 --�E-��.,�;o�R��G- _ _----_ __--_ - -_ _-- =— --- --MO: 40583 �� TNANK l'OU FOR THIS OPPORTU;!TY ..........................•--•--------•---...---- - ,V�� ITISOURAIAnTn ?ER- •............................ TO ScR OU <, �u�� s�:,#�r�.i"�.�'.,�'�' .?� `�e"��+�..a'�:�x�' . . .�� i FGRPP,/i;�I_L?�HE REPAIRS RECil1E`TEt� C/S: CUSTOh1ER HIT POT HOLE NEEDS TIRE REPLACED POSSIBLY ALL SC�: rNa:, REc��R OR�E� rC� 'r �u�? FWR. CHECK AND ADVISE. �C01,^,PL=TF SAl"ISFACTION. i'r i��R REPLACED ONE RIM. MOUNTED AND BALANCED 4 TIRES. VERIFIED �e�RVICE tifdrlS SATISACTORY '"tLl OPERATION ?"` Y"OUR FRIENDS. IF N�T.FLEASE '�L� TS---...qP.'-•-FP-Nl�1SER---•-•---------DESCRIPTION.............•--....UNIT '�i�iivl;�tEu1AT�i_,r, 1 4726135-AB WhIEEL STE �� 75.81 .^—� d./� � � �� i 4 001548 TIRE �Z]L..�l1> 486.00 w�'C.C�["' 70TAL - PARTS 561.81 � �';�/� ,_ f�� ( 1 C.. � t�ISC---...CODE---•--•-DESCRIPTION--•••-------•-------•--------•-COKTROL NO...._-... �----- � TWA TIRE I�EK ADVERTC SIN6 WRITE OFF -100.00 ��"(�= �J �—�� , TOTAL - MISC 0.00 /�, • ,�# i TOTALS-•----••---••------•--••----------------------••----•---••-• � � PART�S 561.81 .> �m"'�� ■f�l�� .mB# 1 JOURNAL PREFI�( FICS JOB# 1 TOTAL 646.53 2 CtIARGES.................•-----•---------•--•-------•i---------------...-----._...._....._ - ---• ----- .... QR-:'- ..� _ ..- --. , � -.. %'" ,� 'r -sy �; '�; �a .. �� 18A0 QUENTINEAUELIS . ��s.�'t�e�'�'�a� �� .<., -��,.�.`'»�'..s,.��''��N .��i��'4��..w�::..� �;�.�1�."�.. ..'4.�'.�:�. �T . L U U I S P R R e M f1 F 5 4 1 6 PLEASE PERFatM A 16-POINT INSPECTION AND FILL OUT THE � ATTACHED INSPECTION SNEET. PERFORMED MULTI-POINT INSPECTION. a a�z a�z o i a 1 s:a i : 1 a MID : OOG400002031945 2 TOTALS------••---------•.......................................... . 05490794 TID• 329223024998 JOB# 2 JOURNAL PREFIX FICS J0� 2 TOTAL 0.00 CREDIT CRRD ISC•-----CODE--------DESCRIPTION•-•--•-----•--••--•-------••-•-CONTROL NO-------•- � A E00 ENVIRONMENTAL-HAZARDOUS DISPOSAL 3.50 U I S R 8�L E A SS SHOP SUPPLIES 8.47 TOTAL - MISC 11.97 c�RO: xxxxxxxxxxxx�eia TI��------•-------•--•--••---•-^-•-----------------•-•------------------...--- I NVO I CE 205660 STOMER HEREBY ACKNOWl.EDGES RECEIVING e a t�n n: o 0 0 o s a ORIGI NAL ESTIMATE OF 5700.OO (+TAX) A P P C o d e s o 0 s 2 6 0 NT$-•------------------•--•------------------•--------------------------...._.. Entry Modas Sw1Ped IT created 2014-04-28 11:28:OOam taken by Rachel Frami REPLACE TI n o d e � o n� i n e FOR POINOLE AND MAY POSSIBLY WAN1' TO BUY ALL 4 PLEASE (�T QUOTE SALE RMT $699,3fi ;T! � CUSTOMER COPY � I , � ,� i > ! i , pAGE 7 OF 2 CUSTOMER COPY [C�NTINUED ON NEXT PAGE] 08:19pm t. L�.�s.a.._�_..��..�.��..s_._..�_�____�