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Lien REC�i�JE� �1AY 0 9 2Q14 iv0'I IC�; UF CLAIM F(7RM to the City of Saint Paul, Minneso�TY CLERK i1;;,;�, ,��;;r S;ate�7utute 4t��:.US states tltat " ...every person...whu rluima dumn�;es frotn Qny municipality...shali cause tu be/�resenferl!o�hc _�.��e�uiiri bcxh•uf thr rt�nricipuliry cvithin I80 days uftrr tne alieged lass or rnjurv is discovered o notice staring Nte li!ne,place.�rntl c irrumsrunees thereoj,and ehe amouat af comyen.salion ur utlzer refrrf demanded." 1'leacr complete this form in its enNrety by clearly typing or printing your answer to each question. If more space is necrlcd,attach additlonul sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much inl'��ranation as neressary to explain your claim,and the amoant of compensation being requested. You will receive a ���vt�cn urknowledgem�•m once your form is received, The process can take up to ten weeks or longer dependin�on the na�ure��f your claim. Chis form must be signed,and both pages completed. If something does not apply,write`N/A'. s�;ND COMPI,ETEn FURM AND OTHER DOCUMENTS TO: CITY CLERK, 15 W EST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 � '��`-� Middle Initial �' Last Name �--��=r'+ Fir.i :\,:�ii� _'_'., — ( u�,��>;u��. �,��Business P.'arne ___ _ —_- \�� 1 ;��, ,�n ]nsurance('�>mpany�? Yes� If Yes,Claim Number? ___ __^____.. titr.�,i :�,���res� _��_>�� 1S� `��- --- c'�t, Qo�_�R.���.. State I'l �� _..Zip Code� ��o I�a�t ii n�� Phc>ne I�)��3_-��Cell Phone�tr �33�o��t Evening Telephone ( �� Uat�� t�t .�ccident/Injur� or Date Discovered�____d/1� Time � �3G �`pm F'lr,�.�.�� ��.�tr, in detail, v liac uccurred{happened),and why you are submitting a clairn. Please indicate why or how you i,ei �h� C'ic� ot�Suint P.�ul ar its employees are involved and/or responsible for your darna es.__�__�s,,_`.�_�. - -- CX�f".•►�- - --�%�---- ' �-- _ "�,----N_.:r� - �o,���__.. t� �Mj����n_____ �- c.�� h ' '�-- �..� __._ . `�_ - rl — `' ' �. �\ . ;.� --.._. ,'r -- - _ 1� �M�-�`�1.i,.\ t^�r. � l -�"1 .. . _ '�._�_��'���- v`'9�r1'4'[-' _- -` Pl�,��� �h��ck the box(e� � th�u most closely represent the reason for completing this Porm: ❑ �?� ���hicle ��<is dair.�ged in an acr.ident ❑ My vehicle was d�naged during a tow �l� �clucle wa�darr���ged by a pothole or condition of the street ❑ My vehicle was damaged by a plow I] �i� �..I�i��le wa;wron,rfully tuwecl and/or ticketed ❑ I was injured on City property L� t>ih�� �.}pr of propert� dutnage-please specify _____ - -- (� ()ih�� ;��E�e of injury - please specify' — In order to E�rocess your claim vou need to include conies of all appli�abie documents. }i»� r.fi� ,I;umti types lis �•d below, please be sure to include the docun�ents indicated or it will delay the handling of �c�u: �i;:ini. Documenh W]LL NOT be returned and become the property of the City�. You are encouraged te�keep a ct���;, I��r �uurself befor�• subrnitting your claim form. O Property dair,agr cl�iims to a vehicle: two estimates for the repairs to your vehicle if the damage exceed� ��(x).(K1: ur the ,�ctuul bills and/or receipts for the repairs �) 'Towing elai r�s: legible copies of any ticket issued and a copy of the impound lot receipt C) Uther prope:�y du�nage claims: two zepair estimates if the damage exceeds$50Q.00;or the actual bills ..nclior receipts t�>r the repairs; detailecl list of damaged items 7 lnjur}� clairn� m�dical bi11a,receipts U Pl�otographs ,�re always welcome to docurnent and support your claim but�vill not be returned. Yage 1 of 2-Please complete and return both pages of Claim Form I •d SL6ZEE9TS9 sn�d S3bIl WdB0 �6 �TOZ BO �eW Failure to c��n�plete and return both pages will result in delay in the handling of your claim. ,�I I (.'laims-nlease conit�lete�his section �Vert� tli����° witne�ses t��ehe incident? Yes No Unkn�wn (circle} Nrrn i��� N�eir names, ad�iresses and telephone numbers: �� e�.• ;1�,� }�c�lice or law :nf'orcement called? Ye.s No Unknown (circle) I! ��•� ��h;it depai�tmeni ��r ubency? _Case#or report# 1� 1-��r< <Il,l rhe accident ��r iniury take place? Provide street address, cross street,intersection name of park or faciliiy. rlu���: i,inclmark, etc. 1'leay e as xailed as possible. If necessary, attach a diagram. l�J�n:�-t. b��_�� _ '� �1�1.�,a^c�_ ��4�.h�-� — - ------ �f j�'.s�" -- Plen.� ii:�ii�a[e the amocnt vou are seel:in in compensakion or what you would like the City to do to resolve this clsiim i�� �, u: -,iiistactinn. — ------ .�1--`�-!i� -- �'ehicic t'Iaims- leatir com lete this s ti n ❑ check box i this secti�n does not a �l 1'�>ur \-�hfcle: Ye,ar__ Make 6�n't�°��- Model 1 C'�� Licens�� Plate Number State Color �5,1��� Registc�ed Owner 1 `5�. �-=�� � Driver��f Vehicle��S�,._�°�_ Area D,,maged____�____�-'M.e�.� Citt '� ,�I„�lc: 1'ear_ _ Make Model --_— - Licens�• P1ate Nurnber_____.�� 5tate Color Driver ��f�'ehicle(Ciry Employee's Name) _ Area L<<cnaged [n ju.r�_t.'laims-,pleas�complete this seCtion ❑ check box if this section does not avph� Hc>v. ��rr��you injured'' - ��v'I�;;� ��;irt(til of�e>ur bc�ly were injured? ____ ___.___— — }{�i�,, ,�,�, ��u�h[ medicr.l treatment? Yes No Planning to Seek Treatment (circle) �'�I,��,;.i�l �uu re�eive l ,.�itrnent? �___ __(provide date�s)1 Nuni� c:•f �1edirul Provi�':er(s): — ---- I ;�<1�ire... _-------- - Telephone _. Oi�l ,,,�, n�i�s H�cxk as�i ;•e.tult of yourinjury7 Yes No �\ I�:r�, �.��i tiou i»i5s wo�}.? --- -- �(Provide date(s}) N�inr� ,,� ,.�•u•E?t,rlpyer _ --- �- ;��I:irc•,• �.--- _� ---.----.-- Telephone —. �Check here ii vou are attaching mor�pages to this claicu form. Number of additional pages� . hti� ��r;;frilt� thts form, you are stating that all information you have provided is true and correct to the b��st n/ 1�<►u r kn�wledge. L.nsigned forms will not be processed ,Sulrn�il�i��g a false cl�rim can result in prosecution. Date form was completed — Print the Name of the Person who Completed this Form: �`��-°`°•� i"''4"� - --- � tiignature nf Person A•laking the Claim: �_ - - --- Ri��i ��! 1,1,ruary '_t)I I Z •d SL6ZEE5 T S9 Sf11d S321I 1 Wd80 �6 b T OZ BO �eW Customer Ir�voice TIRES PLUS Service Advisor: '`���� '� ROSEVILLE 32 MAT7 "�� ��E'' `'' '" 2730 LINCOLN DR 651 633 ��2u4 ROSEVILLE, MN. 55113-1333 200.4 PONTIAC GRAND PRIX GTP [SILVER] LIEN LUCA:, _ 3.8L V6 FI GAS VIN4 OHV �022 ��TH `='� �; Lic#: 817GKK MN Vin #: 2G2WR544241369404 O.AKDAL E r�r,; 55128-5400 In: 05/06/14 8:12AM Mileage: 128,440 E'�-'-:�'-t:=_'_._'=' -_-_- Out: 05/06/14 5:38PM -Stc_;r�_:: �'_t_�� .-_: RETAIL SALE — Rev Hist Unit Extended Job Description /Article # ID Qty Price Price Total WHEELS 1 32 138.75 8Gl_ I ;_ ,� �:f� PUT RF O�v RR ',^JHE�=L ' :-IROME 7017868 02TN 1 138.75 - 138.75 BRIDGESTUNE TIRE 1 32 33.40 �_'f-,E:�"'�< '�F�E SEE IF NEF��� TO PRORATE ���:,�`_�-��; ?'_;i� ;'=.^;ZA VV!SERE^�ITY PLUS BL 225/55R17 146940 02TN � 33.40 33.4( �)T✓ ��'�� �_''�����` '.�;,.E LIMITED ��vARRANTY :. _ _�='DBA3813 WARRANTY FOR TURANZA SERENITY PLUS 225/55R17 97V BL ORIGINAI ARTICLE #146940 PRICE 166.99 COLLECTED 20% REMAINING TREAD DEPTH 10/32 SERIAL# 1VUPDBA1512 EMPLOYEE • BASIC TIRE INSTALL PACKAGE 32 ';I-a� �-L E>=,�,4NCE PARTS 7005989 02TN 1 3.99 3.9�� �=;�BrER .��;� �'E STEM 7015040 02TN 1 2.99 29�� �Ci<�.r' Ti��E R�CYCLING �;HARGE (1) 7075078 02TN ' 2.99 2.9:- ;%.'F-IE^:. �-"�. ,',^:CE L,ABOR � 7006010 02NS 1 9.00 9.00� TIRF irvS-:�,; , �iTION 7015016 02NS 1 N/C NiC: PRT GISC ����,�OUNT EMFL OYEE - BASIC TIRE 7004697 02T -1 6.98 -6.98 INSTA�L P.�t,F�qGE LB�; UISC: ;;;5'�OUNT EMP_OYEE - BASIC TIRE 7004697 02N -1 11.99 -11.99 �NSiA�� 1�,,;=:kAGE COURTESY CHECK 32 ��>P JF r :: i�_ 5W30 FUL�. SYN, FILL WASHER, CHECK AIR IN OTHER TIRES ':)�.'i:'E� � �: .;ECK 7046930 02NS 1 N/C N;;_ ROAD HAZARO 1 32 7.00 '1��.�_!.'':`�� i=,�:`r.��, HAZARD W���RRANTY 7040215 02TN 1 7.00 7.0(�� LIFETIME ALIGNMENT RECNECK 2 32 S� ->>;,<<��. � , ��1;'.I N i Ir E ' !�,1F � ;NMENT RE('�iECK 7022837 25NS 1 N/C N/C Technician(s). �'t r.liC:�-.-���_'� F3LAGE0 25 PATRICK RUHLAND Pay���������� I1 � . ;� , Summary: `�.��<as�r�rC: � 3690 191.92 692042 Parts 179.15 ,<�; �� ,��� ,,,;� 191.92 Labor 0.00 Shop Supplies 0.00 - S u b-Total 179.15 Tax (7.125%) 12.77 Total S 191.92 ,=:� r � � � -��? above goocs and/or services. If this is a credit �;arc� p�.;rcr����r. � �gree to pay :nd comply with my cardholder agreemen! �vitn !ne issuer. , - ,.. . '.i"�,ra����S': .. ... � i_: I ,�I _ ^-.' Gustomer Ir�vo�ce TIRES PLUS Service Advisor: `�` �' � ROSEVILLE 32 MAT7 ��`���� ��`� � � 2730 LINCOLN DR 6.51.633 :'2�-4 ROSEVILLE, MN. 55113-1333 2004 PONTIAC GRAND PRIX GTP [SILVER] �'-'�_'� ��''�:�:',:� 3.8L �V6 FI GAS VIN 4 OHV %022 �5-r'r, � r �: Lic#: 817GKK MN Vin #: 2G2WR544241369404 OAK',�<;',_E: ? ' . -.5128-5400 In: 05/06/14 8:12AM Mileage: 128,440 F'���_��''=�-�-_.�—`'�-__._ Out: 05/06/14 5:38PM Store x 2-����:;;'-; RETAIL SALE Rev Mist Unit ExtendeC Job Description /Article # ID Qty Price Pricc: Total Rev Revision Histo�r: Amt Init ----- ,. - 1) 05/06/2014 11:42AM -151.94 LIEN, LUCAS IN PERSON ----- ._.. _-- >mer S;gnat��e 2) 05/06/2014 05:25PM 0.00 LIEN, LUCAS 651.335.0191 �. ��:� r•,:�,,= �c �ndicate yo�, iave received il��r, T�r:_� ',';.,�-anty �.�lainte�� �nce and Sat�,r�Y ������ .,a! '�!r parts are new unless otherwise specified. I acknowledge notice and oral approval of an increase in the original estimated price. Signature or Initials TELL US ABOUT YOUR EXPERIENCE TODAY AND ENTER DRAWING FOR $500 IN SERVICE! Call 1-800-754-9817 or go to www.TiresPlusSurvey.com; Enter code 244224-122018 Offer axpires 10 days from date of invoice. Good at all participating locations. .. .�'d�.�. �M�Y��1�.'�rV149�,b.�i.;�iF ._ _ n __ � -�:79i75 REV'._�: �.. _ I ' `� �.' ��� ra, s,, ;��,y ,�,+ ,� }�:.•;��^e��.'�ie��� � +r s� rr� �s�Zc � r .. . �.�; � �� {� �� '� ...� s� ,z , � !. 1 `��4� ��,� u H.'s i. Jk, t ��� 11' .i{ . '� . �� z�?�k ��.` . �, 3, _,�yn," a s k !r t _ w � ^�-- _ �< �� �-�a� •,P •r �� ; .. .Y� � �}� � . �. , �z f� s ��, , t �� :'; r���1 x� �+�h� + 1��� S t"7� Y�a+`� h y 4 as i�� F� �'"�' �i- � $.. 'Y; ` �. � �t,�0 i f• � . � . - t�j ^, Y e, t � R � � }� .. �� .,-at� '�r+,'� ' `;*t��� �n -, :.��� �` .� �{• S y � i t d`c }. � : #. �.t �'�' .V � }'� �,,� �.�.a �'j`. f;. ; -'.}a . �.� y, u,, � �{� , y: b ,�. � . .. g ,� t�- � �' i�. � �< �. ' �. � ' : �� � ��.� # �` � � �� �� �. 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