Carter, Patricia RECEIV��i !
�iAY 05 2014 F�EC���1�� ''
NOTICE OF CLAIM FORM to the CityLe�-�i���, Min�@��2014
Minnesota Stare Statute 466.05 states that "...every person...who claims damages from any municipality...shall cau.��qe�re�iea��
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other redief 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 compensation being requested. You will receive a
written acicnowledgement 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 PALTL, MN 55102
First Name�� b� � C, � C� Middle Initial�Last Name ('� r �(" ��
Company or Business Name
Are You an Insurance Company? Yes,�� If Yes,Claim Number?
Street Address / � � � �(��r�.� �
City�e t�Y► YYl B-Yl,y�, State � --�- Zip Code_y_���
(�s!- aS�9 - ��q
Daytime Phone(?���- 7nCf�Cel1 Phone( ) - Evening Telephone(�)��_(��
Date of Accidend Injury or Date Discovered '`1/ - �� —/ y Time ` am pm
Please state,in detail,what occurred(happened),and why you aze submitting a claim. Please indicate why or how you -}-
feel the City of Saint Paul or its employees are involved and/or resp nsible for our damages. ' � `E 5/
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- , e � , _ ��. ' �w�
,� w�.
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 conies of all annlicable 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 WII,L NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
�Properiy 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 bilis
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
i
�
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 wimesses to the incident? Yes No Unl�ow�ii (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes N�o Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersec6on,name of park or facility, t
closest landmark,etc. Piease be as detailed as possible. If necessary, attach a diagram. ���/y3 /v�.�-3rc�,
�
Please indicate the amount you are seeking in compensation or what you would like the City to do to re lve this claim �
to your satisf tion. � �� � �
�
VehicIe CIaims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year o�u.�� Make � 1! Model
License Plate Number State � Color
Registered Owner � `
Driver of Vehicle � r'` � � � �
Area Damaged ' � Q h���� r E-
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In,iurv Claims alease complete this section ,�check box if tlus section does not auulv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatrnent(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? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
,�] Check here if you are attaching more pages to this claim form. Number of additional pages � _.
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 �/—/ y
Print the Name of the Person who Complet this Form: t'�Ir i i � �CLV� �-'r
�- .
Signature of Person Making the Claim:
Revised February 2011
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T -i--�� FRM# 5929874
DATE: 04-30-2014 TIME: 12:18 PM
, -a- : -.- . .- . .
MIKE CARTER 2012 CHEVROLET MNM 14
1743 96TH AVE IMPALA 13341 60TH STREST N
1T"OPT. LS STILLWATER NIN 55082
HAMMOND WI 54015 PHONE: 651-351-5172
(H) 715-796-7058 CARRY OUT 021 TIMOTFIY M CHRITZ
TORQUE SPECS: 100 WORK ORDER#
...,� �o ..� � ,� - - • -' •.
12980 NRM 2 P225/55R17 95H BSW GDY ASSURANCE TOURING .00 117.59 235.18
WARRANTY: MILEAGE- 70,000 SEE REVERSE SIDE FOR WARRANTY DETAILS
COMMENT: BOLT PATTERN: 5-115
COMMENT: INFLATION F:30 R:30
80017 NRM 2 CERTIFICATES FOR RBFUND,REPLACEMENT .00 16.U0 32.00
80224 NRM 1 WASTE TIRS DISPOSAL F8E .QU 3.00 3.40
80219 NRM 2 INSTALLATION & LIFETIME SPIN BALANCING .00 16.00 32.00
86666 NRM 2 LIFETIME ROTATION LIFETIMfi REPAIRS INCLIIDED .00 _00 .00
86607 NRM 2 #VS-950 TQ-12 T10 TPMS VALVE KIT (RUBBER) .00 7.50 15.00
COMMENT: LOOSE ALLOY WHEELS
COMMENT: PUT SENSOR ON NEW WHEEL SAVE OLD FOR CUSTOMFsR
Since you have purchased fewer than four tires (or wheels) , we will mount the new tires on the
rear of your vehicle for best safety and handling.
The tire and/or wheel you have chosen is different from the original equipment provided with
your vehicle and may change its handling or stability characteristics.
Further information is available from your Disc�unt Tire salesperson.
Signature on file
DISCOUNTTlRE..COM
a
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� t � � FRM# 5929874
DATE: 04-30-2014 TIME: 12:18 PM
. • -.- . -e• • . •• . � s
MIKE CARTER 2012 CHIs'VROLST MNM 14
1743 96TH AVE IMPALA 13341 60TH STREFsT N
17"OPT. LS STILLWATER MN 55082
HANIl�fOND WI 54015 PHONE: 651-351-5172
(H) 715-796-7058 CAR12Y OUT 021 TIMOTHY M CHRITZ
TORQUE SPECS: 100 WORK ORDER#
��m�s � ' r _rd s.. . ' - a .. � . t
NOTICE
NOTICE
United TranzActions is our return check processor. Returned checks are subject to service
fees as permitted by law. These fees and/or service charges may be collected electronically.
Debits will be shown on your bank statement as: TRNSFYF Fifth Third Bank National Check.
For information call United TranzActions at: 800-407-7459.
SUBTOTAL: 317.18
TAX: 17.83
TOTAL: 335.01
CASH: .O1
NM 3201 A# 409214 CHfiCK: 335.00
T$NDERED: 335.OI
Signature on file
t]ISCOUNTTIRE�CQM
Twin City Wheel Repair Repair Order#DO2gJ2t�
� .
2370 Leibel St. Suite 101 -, Date . 4/30/14
White Bear Lake, MN 55110 � Page : �
(651) 407-3636 '
� Center: �
twincitywheel.com __._
Customer: CARTER, MIKE Vehicle : 19 �
Address : 1743 96TH AVE License : Kev :
��ty: HAMMOND, WI 54015- VIN :
HOME : ( 715 ) 796-7058 Ext: Engine : Trans :
WORK 1 : ( 715 ) - Ext: Mileage : 1
Op Tech Description Labor Parts Subtotal
WHE004 MJ6 (1) STRAIGHTEN ALLOY WHEEL @75 (DEALER RATE) 75.00 75.00
WHE010 MJG (1) STRAIGH2EN AND REppriR IN3IDE LIP CRACK(DEALER RATE) @$100 100.00 inn no
C�i�i c� �� t,t S`e-
��,i 5 �,1�+�'l ��(
1 hereby authurize the repair woAc to be done along with the necessary parts and matenais and hereby grant you and/or your employees Labor: $175.00
permission to operate the vehicle herein described on streels,highways or elsewhere,at your disaeiion,for the purpose of testing and/or
inspection An e�cpress mechanics tien is hereby adcnowledged on the above vehicle ta secure the amouni of repairs thereto.I understand that Parts : $0.00
dea�erlowner Is not responsible for delay or other wnsequence due to the unavailability of parts ahfpments beyond their control.Not Sublet: $0.00
responsible for damage or artides left in car in case of fire,theft or any Wher cause beyond our control.
WARRANTY ON AUTOMOTIVE REPAIRS IS 12 MONTHS OR 12,000 MILES WHICH EVER OCCURS FIRST,UNLESS SPECIFIED Other Fees: $0.00
OTHERWISE WARRAN7Y ON WHEEL REPAIR IS ONE YEAR ON WORKMANSHIP AND MATERIALS.WARRANTY DOES NOT COVER
SUBSEQUENT DAMAGE CAUSED BY CONDITfONS BEYOND OUR CONTROL. SIJppI}/CF18�g $O.00
Due to the nat�re of wheel repair there are times when a wheel is rendered irreparable.We reserve the right ro deem a whael irreparable.We Subtotai : $175.00 �
will not be responsiDle fw repainng or replacmg a wheel deemed irreparable.Rims not picked up in 30 days will be sold to detray expenses Saies Tax: $0.GO
X
Wheel deemed ureparable (Not fixable)Customer is advised Mal wheel/rim may be unsafe for Paid ey: Total : $175.00
use,n presen�condition Ch2Ck
X Pay Ref: Paid : $175.00
Due : $0.00
Thank you for your businessi _ -----�--
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