Wiles RECEIVED
MAY 12 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
CITY CLERK
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipadity...shall cause to be presented to the
governing body of the municipality 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 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 pmvide as
muc6 information as necessary to egplain your claim,and the amonnt of c�mpensation being requested. You will receive a
written aclmowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your ciaim 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, SAINT PAUL, MN 55102
First Name �-4-Llt,t.�.t_ Middle Initial L Last Name W��S
Company or Business Name
Are You an Insurance Company? Yes/ io If Yes,Claim Number? �
�
Street Address ��� �1�M4�'� � '
City G 0(LVt�{' State, �(J Zip Code S�7'?-a
Daytime Phone( ) - Cell Phone(`�g)� I -�Evening Telephone( ) -
Date of Accidend Injury or Date Discovered S L�-I � �`� Time�am/�m
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. � a-S d:1n�
�rv� t 2-C-u�i �1� '�n d� l� -
,►-� o� h (i�nnn t.vY.v� o�lNt � ��r �' �-
p�, '�'�, I�la� ' o� �rv� i S ' vNclil�"
r�. x,n�� � cw -��v rxn
,¢.�hi i e� °��2
" , 'h 1/� • (AN'!� S�� '
�hcS�t.) f��Oca�l��"` �n �r�'wb4i°'^ v�c V►J��S �P,�c(w�cx�c.�'v►7 y� a.n�.c�1w�•
Pleas�e ch c�the box(es)that most closely re`present the reason for completing this form:
� My vehicle was damaged in an accident 0 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
0 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 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 yo rself before submitting your claim form.
�roperty 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
� Towing claims:legible copies of any ticket issued and a copy of the impound lot receipt
� 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
� Injury claims: medical bills,receipts
�]/�hotographs 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 witl result in delay in the handling of your claim.
All Claims—nlease complete this section
Were there wimesses to the incident? Yes No Unknown (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.� ha
�a,�1rVi.wJ �/e. �dtin� sbUf�NnYJOIk►�.Jl �¢�twc�n cS��Avt a.r� ��wl i� ��/`e •
Please indicate the amo nt you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � I�LI() �I Z. i r� r.��nn(1t.hSa�ticm �v f.ov�+' rNnR GO��S � Y�e,dJ0.Ar ��.
IN�� annd -I,�r.c a�w+nn a.ow -1-o w�.,� ea.�. aiw��► w-�� ��u. .((�,.,�';rv,�t e,r� v�c-a,ln-c�n,,w,�1-.
Vehicle Claims—alease complete tiris section 0 check box if this section does not avvlv
Your Vehicle: Yeaz�j.�Make l:114 _Model �D�-T�
License Plate Number�� ' A State MN Color S+tt,i g1UlL
Registered Owner �-� �
Driver of Vehicle � �
Area Damaged � �+�- h�^^ �^ '���' �' ���
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniury Claims—please complete this section � check box if this section dces not avvlv
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
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.L.
By signing this form, you are stating that all information you have provided is true and correct to the best
o f your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed � �rP� 1�
Print the Name of the Person who Completed this Form: c�'1"�wl w� �
Signature of Person Making the Claim:
Revised February 2011
� ���_��=- �(� 1701 American Bivd.W.
�� ���v� � � ■�ia o Bloomington, MN 55431
B'O�'� �� Phone 952-258-8400 ��
� Fax 952 258 8401
CELL: 218-879-72 4
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STACEY WIIES
8128 SIMQN tt� '�"""�i�u°°a n�`rv�mwr� v�v�av�xut�s
CLOQUET, MN 55720 14/KIA/FORTE/4DR SDN EX AT
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218L591-2786 MO: 5538
---------------------------------------------------------------------- The factory wananty constitutes a!!of the
� �.. _�" j �� --- warranfies wifh respect to the sale of thrs
CUSTOF�R STATES DRIUER FRONT TIRE�IS FLAT. VEHICLE WAS iteminems.The seller hereby expressly�s-
' T(U�D IN. CHECK N� ADVISE. ciaims all warranties, either express or
SEE LINE �!2 implied, including any implied u.arranty a3
merchantability or fitness for a particular pvr-
� pose and ihe setler neither assumes nor
P/I(tT$------QTI(---Fp-MIlBER---------------DESCRIPTION----------a---------UNIT PRICE- autho�izesanyotherpersontoassum.ef�rit
,�(� � 1 TOTAL PART$ 0.00 �Y����tity in connection x�ith the sale of this
itemJ'rtems.
,]OB # 1 TOTAL LABOR & PARTS 0.00
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MOtMT AND BALANCE Ot� NEW TIRE PER CUSTUMER ftEQI�ST.
REPLACED RIM A�D TIRE AS NEEDED
PARTS------Q1Y---FP-I�ER---------------DESCRIPTION----------- --------UNIT PRICE-
JOB � 2 1 t�X17-21545H CP 671 H BW 106.80 106.80
�OB � 2 TOTAL PARTS 106.80 ��
JOB � 2 TOTAL LABOR 8 PARTS 126.80'
pERFpRM FRONT SUSPENSION AlI(�NT SERVICE. - �
PREVENTIVE MAINTENANCE
pERFpRMEp FRONT SUSPENSION ALI(�ENT SERVICE. ADJUSIED TOE.
CASTER. AND CAMBER TO FACTORY SPECS. CENTERED STEERIlIG MHEEL
PARTS------QTY---FP-IiUlBER---------------DESCRIPTION----------�-�"3 TOTAL PARTS 0.00
JOB # 3 TOTAL LABOR 8 PARTS 79.95 a
- - - - - - -- - - -- -- --_�;. --- - s
*** 7.500 Mile Service at 7504 *** � _
7.500 Mile Service at 75Q0 CashforYourused VehiGe.
l�IA In-Tank Fuel Injector Additive your car c�Id be worth rrwre than you
� NINPI� Inspect Parking Brake think! qnd we'ti buy it! (Even 'rf you don't
o MINSAF Inspect Air Filter txry from us). We'I� quote ANY vehic�e,
o MINSB,DC Inspect Bal l Joi nts � regardless of condition.lf you accept,you'll
m MINSQAB Inspect Drive Axles 8 Boots ,�k a�y���t►.You'll r�ver find
� MINSS(�H Inspect Steering Gear a faster,simpler or sater way to seil your
m MINSSL Inspect Steering Operations b Linkage � y�,� �� � p��� �r your
� MINSTTP Inspect Ti res 8 Ti re Pressure � �;��, app�;� or iearn more at
; MIMIH Inspect VacuuA Hoses LUTHERAUTO.COM
Z MpFCM OEM Oi 1 8 Fi 1 ter Change .a���y,����S
¢ *** Ac�itionai Dealer 7.500 Mile Service at 7500 ***
W MINA�F Inspect Ai r Condi ti oni ng Cabi n Fi l ter ALL PARTS NEW ORIG►NAL
e CU$TplIER REll�STS A 7.5K MILE SERVICE.
o p�y�IyE ���. EQU/PMENT UNtESS
: PERFORMED A 7.5K MILE SERVICE AT CUSTOlER'S REQuES7. OTHERWISE SPECIFIED.
� PARTS------Q1Y---FP-MJ�BER---------------DESCRIPTION--------------------UNIT PRICE-
g ,JOB #4 1 1M011-CH056 CHEYRON TECti20N 16.73 16.73
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� PAGE 1 OF 2 CUSTOMER COPY [CONTINUED ON NEXT PAGEJ 03:07pm
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