Bultman RECEIVED
' MAY 05 20i4
NOTICE OF CLAIM FORM to the Citv of Saint Paul, M����E R K
Minnesota State Statute 466:05 states that"...every persors...who claims damages from any municipality...shall cause to be presented to the
governing body of the munici�ality within 780 days after the alleged loss or irtjury is discovered a natice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief clemanded"
Please c�m�►lete this[orin in its e�tirety by cleaNy typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that_�ou will not be cantacted b�telephone to clarify answers,so provide as
rnnch information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once yonr form is received. The process can take ap to ten weeks or longer depending on the
nature of your claim This form must be signed,and both pages completed. If something dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SA�1T PAUL,MN 55102
First Name -��r2� Middle Initial � Last Name�;� �-T dy�.��� ,�'�'
Company or Bnsiness Name
Are You an Insurance Company? Yes o If Yes,Clai.m Number?
Street Address U � � - e S'i '�/=
City ��L.�.`'7 � State �1�J Zip Code�tf,,��
Daytime Phone(��7�ell Phane(_) - Evening Telephone �� � �'�9�
Date of Accidend Injury or Date Discovered �-'d�1' - ,�/ `f Time�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 and/or responsible for your damages.
� � /`� T7.�c�.{ � S` �� i
Please check the bo�es)t.�at most closely represent the reason for completing this form:
❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
�y vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
❑ y 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 arder to process your claim you need to inclnde couies of all aonlicable dceuments.
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 actuat bilis 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 darnaged 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
Fa�nre to c�mp�e and retnrn botb��v�I resutt�+�v�a f�e�of yc��`nt,
��-�caa��t�s��
���eu'� - .t�iite_�i�nt� �'es �o �nl�o� +f�cie}
��e�names,a�re�.-�s anti r�f�hone���er_s: �.
i�Vere the police or Iaw enforcement cailed'1 Y es N � Un�Cnown {circIe;►
�f��.�t��Cme�t ar�er�� C:a�e�c�r r�rt�
V�here fiid t�e acci�ent or�in�ury ta�ce�laceh Provide strcet address,cross stree�intersectian.,n of�ark o�faciiity,
ar
cip sest landmark,etc. Please be as�tailed as passible. �necessazy,attach a�a�rram_p N r' �U�,ti,� �i
,f�a_i�,,�.� z,�� ti.e.� �s i �7 `�`i �u d �"f . r�� t
�1�. S`'s.,�r�, �� __ � �`�,_t�d
��rz��-,ECs�s.
Piease indicate the amaynt vou are seekin in campensation ar what y u wouid I�ce tlie�ity to do�o resolve tlus claim
to your satisfacrion. �l � ^El,q.� Lu. - �SD v o .-y► «.: .9-�'i�°,✓ f.,�.c �v
� ` Tc�i r�r L � 13"• O 7
.�
V 'cle Claims- lease com this sectio� L]checic box.if this se�tic�n does not 1
�c�ur�ehi�e� Year _ /3 � e2 � _e i�f�� L- r� c-}
License Plate Number � f�i2 State /`'l�U Color i.tt=/<
Registered t3wner .� 4 :�r.t.��-_� . L T,�,�
1?river of Vehicle /2.`�-:,v � .:.��T,�,.�s.
AT�1 D�.mat� /iv ,� � 9- /�L.°t�n� rr<.z T
City Vehicle: Year Make Model
i.icense Pia[e I�um�er ,St,ate �`o�,r
Driver of Vehicle(City Employee's Narne)
Area Damaged
In1�ry Claims-please comnlete this section �heck box if this section does not�,.�plv
�iow were you injured�:�
What part(s)of your body were injured?'
Have�ou son.ght medical treatment? Yes No PIanning to Seek Treat�ent{c�rcle)
When did you receive treatment? (pro���(s))
Name of Medical Provider(s)_
tlac�ness -i�iepnone
Did you miss work as a result of your injury? Yes No
QVhen�d you miss wor7�� (Pmvide c�atets)�
Name Af your Employer:
Address Telephone
�t�Check here if you are atfiaching mare page.s to t,i�is ciaim form. i�i`umber at`addifioasl�� _
B�y signin,g this,form,you are statin�that all inforrnalion,�ou have�rnvided is true and correct to the best
of your knowledge. Unsigned forms will nvt be�rnc,essed
Submitting a false claim can result in prosecution. Date form as comptete� �-� - v����
} rrc.�� � � /�,� r�d�'
Print the Name of the Pe�sc�a who Co�pkted t ' c►r�n• �� ���`-� �h�'�
Signature of Person Making the��aim: � G �--'-�
Revised Febniary 2011 � � / ���
5/1/2014
To may it concerns;
I Patrica Bultman on 4-29-2014 was going East on West 7th 5t, i made a left turn on Davern St, heading
North.(See Attached Map)
I do not usually travel this road so I was unawhere of all the pot holes on this stretch of the road just
before the Railroad trackes. I was slowing down for the tracks when I hit a unseen huge pot hole.
which caused my tire pressure light on my dashboard to light up warning me that my front right tire
was loosing air pressure.
By the time I pulled over to the side of the road, beyound the railroad tracks my tire was complety flat
I notitied Mercedes Bent Road Assistance from my cell phone,that I had a flat tire.They sent someone
out to change the tire for me.At that time the techanican said that the tires sidewall had a cut and had
a hole in it. Would have to be replaced.
Because of that stretch of the road before the railroad tracks,those pot holes should have been filled
in and patched.This section of the road had numurous pot holes and that is why I am making this claim
against the city,for a new tire and alignment.
Amount for new tire and alignment $438.07, plus additional$50.00 compensation for time lost taking
vehicle to and from dealership for repairs.
Thank You
Gary Bultman
10814 Pierce St NE
Blaine, MN 55434
763-757-5792
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Page 1 of 1
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CUSTOMER .�`� 1112 3 0 ' 8�310 2 FELDI��fN
•I M P O R T S•
*INVOICE* 4901 American Blvd. West
GARY WILLIAM BULTMAN SR `
• 10814 PIERCE ST NE Bloomington, MN 55437
: BLAINE, MN 5 54 3 4-3 74 8 PAGE 2 Phone: 952-837-6300
HOME: 763-757-5792 CONT: 763-757-5792
BUS: 612-718-5631 CELL: 763-670-7061 SERVICE ADVISO R: 483 Cor Schultz
COLOR YEAR MAKE/ML)DEL f VIN > <;LICENSE '1�IItEA'GE IN/OUT '' TAG
� BLACK 13 MERCEDES C300W4 WDDGF8AB1DG037945 517KRP 16668 16672 T9686
DEL Df�TE P.ROD. DATE V1!ARR. EX'P. �RQT�IIS�D : Pp'N�. >RATE PAYAftENT ? 1NV. DATE
_.
_ __ _
27NOV12 I
27NOV12 D WAIT O1MAY14 0 . 00 CASH 30APR14
R.Q;OPENED RfA�3Y! >: OPTIONS: SOLD-STK:M2909 ENG: 3 . 0 Liter
30APR14 30APR14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
. ; 1 0!00-9:89-�8;-07-01 BRAI�E :iFLUID; _ '`: (N/�I)
�PARTS: 0 . 00 LABOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE C: 0 . 00
_ ___ ___ _ ___ _ _ _ _ ___ ___ _ ____ _ __ ___ ._ _ __. _
_ __ _ _ _ _ _ _ _ ..___ . _ _ _ _ __ _ _ _ __ _ _ _ _. _ __ _
PERFOR�IED FLEX>�B.. :PERFORMED BRAKE FLUID. ..E:LUSH.: 166�9 ..MZLES. :::
_ __ ... _ _ ___ ___ __. . ... _. ... _ ___ ____.. _
' ****************************************************
D** 3'ECH S3'A�ES .HOLE` .ZN '�HE SZDEWA�,L AT 12�F T�RE. IaTEED� :N'EW TIRE 225.,'
40 18-P ZERO NERO--1 TIRE ONLY �
_ _
MAOfl� ;;Miscellaneous Maintenarice -;! R�;pair
376 CPM 54 .40 54 .40
< 1 Q-8-4t)-0$:�:1 P�REL�I> P225�40�Z1$� SKU� 19�57C1:0 r
92H 222 . 50 222 . 50 222 . 50
_ __ _.. __ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ ____ __ _ _ _ _ ___ _ ___ _ _
_ _ _.__ _ _ __ .. _ _._ _ ___ _ _ _ _ _ _ _ _ _._ _ __ _ ___ __ _ _
PARTS: > 2'22. 50 L;AB0�2: ', '�4 .4!0 OTHER: >; : 0 .0:!0 TOTAL '<LINE''D_ 276 . 9:0
_ _ _ ___ _ __ _ __ _ _ _ _ _ _ _ ,; _
MOUNT AND BALANCE R/F TIRE. -
*�**,��s�*��x**��****x��***�k��*,k�;t**�c:,,4:�****!�r*�**�*��<w**� :
_ _ _ ,,s: _ _ _. _ _
E** Alignment, Front and Rear - Check�, and�d�ust. RECOMMEND ALIGNMENT.
. AT,IGN PEI2�'ORM 4 WHEEL, aAL3GIiTNlENfi' �, ��;�'````�'��.� f�' .
7004 CPM �" 139 . 00 139 . 00
' PAF2TS. ; <; D. 00 I�ABOR: : 13.� . 0 0 OTH��.,..-,�.a� .p ;.Q .0 0 T:bTAI� ;LINE;E: 13 9 . t3';0
• PERFORMED 4 WHEEL ALIGNMENT
_ ___ _ _ ____ . .. _ _._ __ _._ ._.....__ __ _ _ .__.._. __ . _ __ .. __ ___ __
*�r;.**�**:**�*<�*�*�**��r�*�r**;�****�*�::*:�*�**�x*,�*�r*����r*�*>
EST: 4�3 .36'' ' 30APR1� �$ ,•�:'�> .:51,��F.,4,�.$��.r ; ��
�
P:SF� .ABOUT <FEi1DMANN 'IMPORTS
� *CONDITIONING SERVICES*
� COMPLETE CAR DETAILING
: . ° ; ;CLEAR .FII�M........ ''' i :< .. : : :
• WINDOW TINTING
' PAIN:fiL�SS I)EI�TZ`.. R��?A�i�
__ _ _ _ _ _ _ _ _. ._ _._
_ _ _ _ __ _ _ _ _ _ _ ___ _ _ _ _ __ _ _ _ _ _ _ ____ ____ __ ...__ __
' __ __ _ _ __ _ _ _ _ _ _
DISCL,GIMER OF WARRANTIES I p�$yFtIPTGON; TOTkLS I
THE ONLV WARRANTIES APPLYING TO THIS PAFT(SI ARE THOSE WHICH MAV BE OFFERED BV THE MANUFqCTURER.THE SELLING DEALER HEREBV �� ��� . ^ O
EXPRESSLV DISCLAIMS ALL WARRANTIES,EITHER EXPRESS OR IMPLIED,INCLUDING ANY IMPLIED WARRANTIE90F MERCHANTABILITY OF FITNESS FOR LABOR AMOUNT .�
� A PARTICULAR PURPOSE,AND NEITHER ASSUMES NOR AUTHORIZES ANV OTHER PERSON TO ASSUME FOfi IT ANY LIABILIN IN CONNECTION WITH THE
� SALE OF TNIS PART(SI AND/OR SERVICE.BUYER SHALL NOT BE ENTITLED TO NECOVER fROM THE SELLING DEALER ANV CONSEQUENTIAI,DAMAGES, PARTS AMOUNT 2 2 2 . 5 0
�DAMAGES TO PROPERTY,DAMAGES FOR LOSS OF USE,LOSS OF TIME,LOSS OF PROFIT,OR INCOME OR ANV OTHER INCIDENTAL DAMAGES.
GAS,OIL, LUBE O. O O
Any warranties on the products sold hereby are those of the manufacturer.As between this retail seller and buyer,the produtt is to be sold'AS IS'and the
� �entire�risk as to the qualiry and pertormance of the product is with t�e buyer.The seller expressly disclaims all wartanties,either express or implietl,including SUBLET AMOUNT Q. Q Q
' any imDlietl warranty of inerchantability or fitness for a particular purpose,and the seller neither assumes nor authorizes any other person to assume tor it any
liability in connection with the sale of said products..This disclaimer by th¢seller in no way affects the items of the manufacturefs warranty.The buye� MISC. CHARGES 5. 9 8
,- acknowledges being so informed Orior to sale.
TOTAL CHARGES 421 . 88
X LESS INSURANCE
� . ��
LAST INVOICE#/DATE: CLAIMS FOR WORK PERFORMED qLL PARTS NEW ORIGINAL SALES TAX 16 . 19
SHOP SALES MUST BE MADE WITHIN 90 DAYS OR EQUIPMENT UNLESS
4,000 MILES WHICHEVER COMES OTHERWISE SPECIFIED PLEASE PAY
FIRST FROM DATE OF WORK. THIS AMOUNT 4 3 S . O�J
THANK-YOU
� �CoDVrigM1i 2(�pp 4DP.Inc.SERVICE INVOICE TVPE 7�512C F T T.F! I7nD V
�
._ _.--
: CUS TOMER #y 1112 3 0 8 7 3 Z�2 FELDl��1NN
. •I M P O R T S•
*INVOICE* 4901 American Blvd. West
GARY WILLIAM BULTMAN SR
10814 PIERCE ST NE Bloomington, MN 55437
BLAINE, MN 5 5 4 3 4-3 7 4 8 PAGE 1 Phone: 952-837-6300
' �IOME: 763-757-5792 CONT: 763-757-5792
BUS: 612-718-5631 CELL: 763-670-7061 SERVICE ADVISOR: 483 Cor Schultz
_ _ _ _ _ _ _ _ ___ _
' ' C17LOR 1'EAR 1�;AK�IMt�DEL ` UIfJ ` tICENS� MILE.{iGE aN!O:i1T TAG <
.BLACK 13 MERCEDES C300W4 WDDGF8AB1DG037945 517KRP 16668 16672 T9686
DEi..D�iTE P,ROD. DATE 1ft!ARR EX�. PfiOM(SEfl P� I�tO. <fiATE PAYMERI'T' :INV D;4TE
: _ .. ,_; __ ,:. _ ...
'27NOV12 I
27NOV12 D WAIT O1MAY14 0 . 00 CASH 30APR14
R.o;oPErvEt� <REA�v�;: s::: OPT�oNS: SOLD-STK:M2909 ENG: 3 . 0 Liter
30APR14 30APR14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
A ;COMPLIMEI�TTAR�.' MULT;I PO�NT TNSPECTTONi
� MPI COMPLIMENTARY MULTI POINT INSPECTION
_ _. _. _ _.. .._ _ __ __ _ _ __ __._ _ _.......___ _ __ _ _..._ _ _ _ _._ ___.. ......_ __ _
__ _ _._ __ _ _ _ __ _._ _ _ _ ___ _ _ _ _ _ __ _____ _ _ _ _ __ _ _ _
_ 376 CPM. _ I 0, 0:0 ; 0 . 00
_ _ _
. �PARTS : 0 . 00 LABOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE A: 0 . 00
�*>*�*ar�:;�**�::*�*�**���*�*��:�v�*�*����*�**�*a�*�**��*��**
B CUST STATES; HIT POTHOLE, DAMAGED TIRE.SPARE IS ON. PLEASE REPAIR
! DAMA�ED; 'i'IRE:, AD'v.. .
00 CUST STATES
! 3 7 6 CPM < Q 0:0 t� 0:0
__ ___ ___....... - __ . __ __.__
PARTS : 0 . 00 LABOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE B: 0 . 00
**'*���r*****�**�*:*�r��*****>���*�*��x�,�*�*���v�*�:����*****:
C PERFORM FLEX - B SERVICE, CHANGE OIL,A�7D�m"FZLTER USING MOBIL 1
SYNTHE'TIC OIL, RQTAZ'Ei AND BAL�CE F�IR��; CH�NGE :CABIN FIL'.PER, >
CHANGE WIPER BLADES, CHECK AN� TO g,.OFF�FLUIDS, CHECK BATTERY
ANI3 CI�RG�TG:: SYSTEM,CHECK<::BRA�� AND LT.�BRIC�iT� M
_ _.�
' CAUSE. _�,.. . ..._ �
20K PERFORM FLEX - :B .5Ei2�ICE.�: �H�]'�,�.��3:," AND
•. FILTER USING MOBIL 1 SYNTHETIC OIL, ROTATE
_ __ _ __..._..._.. . ___. __.. .....__ ._.. . _.. _ .__.. ...... _ ___ _ __ __ ___ __ ._ _ _._ _ _
�;ND BALANCE TSFt:ES, �i3ANGE GABTN ;FTLTER� _
CHANGE WIPER BLADES, CHECK AND TOP OFFrn
FLUTDS, �FiECI� B�T ,`'T�'.,��������C��.RC-���G�°. > , �;> �
� SYSTEM, CHECK BRAKES�;�a�LEAI�, AND„�L�TBkZ�CP,TE..M_,. _ .
_ 3 7;6 WPP�f <: t N��<)
1 276-180-00-09 TS OIL FILTER ELEMENT (N/C)
; 1 �;076D3-0141D6 SE�1L RII��;;'�LRIJ'B _ ; {N/G'}
. 9 Q 1-09-0144 MB Mobil 1 Synthetic 5W40
4 Fc��inLil� :M I �l�tf�:) :
1 212-830-03-18 COMBINATION FILTER (N/C)
1 : FLUSH BRAK� �'�,LTID / �'L�T3'S� QUT O:�,D BRAK� :F'LUID
AND REPLENISH WITH MERCEDES BENZ QUALITY
BRAKE.:�'LUID f HL,E�D A�R .FROM; SYSTEM / CH�CK
' BRAKE CALTPERS AND BRAKE PADS / TEST DRIVE
� ROR QU�1ZT�'X _
376 WPPM N C
DISCLAIMER OF WARFiANT1ES ' > ❑ESCRIP7rd�1; TOTALS!
THE ONLY WARRANTIES APPLYING TO THIS PARTISI ARE THOSE WHICH MAY 9E OFFEqED.BV THE MAN FACTURER.THE SELLING DEALER HEREBY �
EXPRESSIV DISCLAIMS ALL WARRANTtES,EITHER EXPRESS OR IMPLIED,INCLUDING ANY INIPLIED WARRANT�ES OF MERCHANTABILITV OF FITNESS FOR LABOR AMOUNT
A.PARTICUTAR PURPOSE,AND NEITHER ASSUMES NOR AUTHORIZES ANV OTHER PERSON TO ASSUME fOR 1Y ANV LIABILITV IN CONNECTION WITH THE
. �SALE OF THIS PART(SI AND/OR SERVICE.BUVER SHALL NOT BE ENTITLED TO RECOVER FROM THE SELLING DEALER ANV CONSEQUENTIAL DAMAGES, PARTS AMOUNT �
•' DAMAGES TO PROPERTY,DAMAGES FOR LOSS OF USE,LOSS OF TIME,LOSS OF PROFIT,OR INCOME OR ANV OTHEF INCIDENTAL DAMAGES.
GAS,OIL, LUBE
. Any warrantia on the products sold�hereby are those of the manufacturer.As between this ratail seller and buyar,the product is to be sold"AS IS"and the
ennre risk-as to the quality and pertormance of the product is with the buyer.The seller exDressly disclaims all warranties,ei[her ezpress or implied,including SUBLET AMOUNT
.� �any implied wairanty of inerchantabili[y or fitness for a particular purpose,anC the seller neither assumes nor authorizas any other person to assume tor it any
, •liability in connection with Ihe sale of said products.This disclaimer by this seller in no way affects the items of the manufacturer's warronty.The buyer MISC. CHARGES
acknowledges being so informed prior ro sale.
TOTALCHARGES
X
LESS INSURANCE
��LAST INVOICE#/DATE: CLAIMS FOR WORK PERFORMED qLL PARTS NEW ORIGINAL SALES TAX
' SHOP SALES MUST BE MADE WITHIN 90 DAYS OR EQU�PMENT UNLESS
" 4,000 MILES WHICHEVER COMES OTHERWISE SPECIFIED PLEASE PAY
FIRST FROM DATE OF WORK. THIS AMOUNT
� THANK-YOU
�' LopY�iph�2000 R�P,Inr..SEPVICE INVOICE TVPE 2-512C � F I LE COPY �