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Kline RECEIVED MAY 12 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minn��t�a CLERK Minnesota State Stntute 466.05 states that "...every person...wha claims damages from any mu�iicipaliry...shall cause to be presented to the governing body of the munictpaliry within 180 days nfter the alleged loss or injury is discovered a notice stating the time,place,ancl circumstances thereq�;and t{:e amoiint 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 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 � Middle Initial�Last Name��1(1er Company or Business Name Are You an Insurance Company? Yes No If Yes, Claim Number? Street Address City � \('� � State W� Zip Code�� Daytime Phone(�)�'Za Cell Phone( ) - Evening Telephone( ) - Date of Accidend Injury or Date Discovered �'/��' Time �'(� aQ/pm Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how ou feel the City of Saint Paul or its employees are involved and/or responsible f r your damages.� � �►rY,� .J . .� Cr � �, , c 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 toweci and/or ticketed G I was injurcd 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 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 returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. �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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please complete this section Were there witnesses to the incident? Yes No nknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes No 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 or facility, closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. 0 l�_ �D�nrq � Please indicate the am unt}'o, re se king in compensation or what you would like the City to do to resolve this claim to your satisfaction. � ��'L� ,7� Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year Z013 Make Model � License Plate Number — State �� Color � _ Registered Owner �� Driver of Vehicl Area Damaged�� "�►Ye City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injury Claims please comUlete this section '�check box if this section does not apply 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): Address Telephone Did you miss work as a result of your injury? Yes No � (provide date(s)) When did vou miss work. ____ I�tame of your Employer: Address Telephone �Check here if you are attaching more pages to this claim form. Number of additional pages L». 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 5r� Il� Print the Name of the Person who Completed this Form: � , L�,�� ` -p� _...� Signature of Person Making the Claim: , � Revised February 201 I - , � !�� 1 Bernard s Northtown Inc. - • ..- •. - - . .- 510 Deere Drive 4/29/14 6004414/1 New Richmond, VVI 54017 SERVICE DEPARTMENT HOURS � � ' ' �• ' (715) 246-2236 7:00 a.m.to 5:30 p.m.Mon-Thur 4/2 9/14 Pre-Invoice Fax: (715) 246-5666 7:00 a.m.to 5:00 p.m.Fri _ _ � bemardsnt.com 7:30 a.m.to Noon Sat 12642 12642 �. . LUKE KLINE, STEPHANIE P • ' • ' - • • 891 170TH AVE 1C3CDFBAODD335658 NEW RICHMOND, WI 54017 • ' ' • ' �' '� ' " '• ' 715-338-2014 11/26/13 ..- :.. .. .- 2013 DODGE DART REDLINE 13-751 � - • • � � -�. ' • 1 - LOF: CORRECTION CHANGED OIL AND FILTER TOPPED OFFFLUID LEV T_�S ' Work perf�rmed by House Tech (999) 14 . 85 Installed 68197769AA :FILTER: ENGINE OIL 1@14 . 70 14 . 70 Installed 68152004PA :OIL: OW20 5@9 .20 46 . 00 Hazardous Materials Charge 1 . 00 CHANGED OIL AND FILTER, TOPPED OFF FLUID LEVELS, PERFORM INSPECTION. OIL CHANGE STICKERS SET @ 3000 MILES SEE INDIVIDUAL MANUFACTER FOR SPECIFIC INTERVAL. Sub Total : 76 . 55 -------------------------------------------------------------------- #2 - 3A1 : MOUNT AND BALANCE ONE TIRE DOT K2X5 YAL8 Work performed by House Tech (999) 14 . 25 Installed TKU 03 :TIRE: 225/45R17 H91 1@134 . 95 134 . 95 Sub Total : 149 .20 --------------- ---------------- Coupon Discount -22 . 60 � TERMS:STRICTLY CASH UNLESS ARRANGEMENTS ARE MADE. "I hereby authorize the repair LABOR 2 9 . 1 O work hereinafter to be done along with the necessary material and agree that you are not PARTS 19 5 . 6 5 responsible for loss or damage to vehicle o�articles left in the vehicle in case of fire,theR,or any . 0 O other cause beyond your control or for any delays caused by unavailability of parts or delays in DEDUCTIB�E parts shipments by the supplier or transporter. I hereby grant you or your employees permission to . Q Q operate the vehicle herein described on streets,highways,or elsewhere for the purpose of testing SUBLET , 0 O and/or inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure SHOP SUPP�IES Ihe amount of repairs thereto° 1 . �Q STATMENT OF DISCLAIMER HAZARDOUS MATERIALS The faclory warranty conslitutes all of the warranties with respect to the sale of this item/items. 11 . 1,�] The Seller hereby expressly disclaims all warranties either express or implied,including any implied SALES TAX OR TAX I.D. , O O wartanty or merchantability or fitness for a particular purpose. Seller neither assumes nor SPECIAL ORDER DEPOSIT itemfitems. —2 2 . 6� MOTOR VEHICLE REPAIR PRACTICES ARE REGULATED BY CHAPTER ATCP 132,WIS-ADM. DISCOUNTS CODE,ADMINISTERED BY THE BUREAU OF CONSUMER PROTECTION,WISCONSIN DEPT. TOTAL DUE 214 .3 2 OF AGRICULTURE, TRADE AND CONSUMER PROTECTION, P.O. BOX 8911, MADISON, WISCONSIN 53708-8911 MATERIAL:ALL PARTS ARE NEW UNLESS SPECIFIED U-USED C-RECONDITIONED R-RESULT Y-RECYCLED • ' • •' •' •'� X m 2012 OEALEftTRACK SYSTEMS,Inc.-Oealershi A iution Gmu B00 965-1028 ►�e.c�,�ep�- Customer Copy ' Bernards Northtown � . 510 Deere Dr New Richmond,WI 54017 715-246-2236 4/29/2014 6:04:42 PM Reference Number: 55218835 Total: $214.32 Transaction Type: Sale Transaction Status: Pending Settlement Card Type: MasterCard Card Number: �ocxxxxxx�oocx5268 Entry Method: Swiped Approval Code: 065082 Approval Message: APPROVAL 065082 AVS Result: 0 Customer Name: KLINE/STEPHANIE P X Please sign here to agree to payment. https://paytrace.com/receipt.pay?id=36994&trarixid=,55218835,&copies=2 4/29/2014