Jackson, Michael RECEI�/EL�
MAY 0 9 2014
NOTIC� Or CLAIM I+,ORM to the City of Saint Paul, Minnes��Y CLEi�K.
Mi�urra�n�n S�aie Srn�ute 466.05.stntes d�o� "...ei�erv persnn...whn rinim.c dunio��e.s.Jrnni nn��mm�icipolih�...shal!cuu.se�o he pre.+•eiitc�d�u dre
�ui�erning l�octy<�/'llre mur�icipalily withii� l80 duVS qfter dre a!le�ed loss or injtrrv is disconered a rrotice slatirrg tlre time,pinre,a�u!
circtrmstnnces fJrerenf,and!/re crnrnunt nf enrripen.snlin�r or olher relic f demm�dec(."
1'lease complete this ti�rm in its entirety by clearly typing or printin�your answer to e�ich question. If morr spuce is
n�eded,attach additional sheets. Please note that you will not be contacted by telephone b 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 acknowled�;ement once your f'orm is received. The process can take up to ten weeks or longer depending on the
nature of yc�ur cl�im. This 1'orm must be si�ned,and both pa�es 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 f � ���G� Middle Initial 'J� Last Name �c.K50►',
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address �e� �l1'{- �,I�� �
City �.�G�(.L.I St�►te ��� Zip Code �r�t`
�—
D�rytime Phone ( -�"= Cell Phone (�)�rz�370� Evening Telephone( 'T'�-
Date of Accident/ lnjury or Date Discovered �'r��e-o�0)� 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 o�f Saint Paul or its e�n loyees are involved a�►d/Qr resppnsibl for your dama�es.
v� v�-. �,r-t -�- '�s �5.0.a.at►�e. �r�e�ic to�- �" �c?�e�le
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P�le�se check the box(es) that most closely represent the reason for completing this form:
NJ My vehicle was damaged in an <lecident ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street O My vehicle was damaged by a plow
❑�Vly vehicle was wrongfully towed and/or ticketed � I was injured on City property
E(Other type of property damage-please specify �i rC �"� 2��h L1a✓v��d- }-�.�f��QA•
❑ Other type of injury-please specify
In order to process your claim you need to include copies of all annlicable documents.
For the claims types listed below, please be sure to include the documents indicated or it will delay the handling oC
your claim. Documents W1LL 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 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; ar 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-Ple�se complete and return both pa�;es of Claim Form
Failure to complete and return buth pages will result in delay in the handling of your cl�im.
All Cl�ims—plcasc comn��tc this section
Were therc witnesses to the incident? Yes No Unknown (circle)
Provide thcir names, addresses and telephone numbers:
Were the police or law enforcement called? Yes Nv 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.
o-�' � Y�a�.r��:-� �- c�,-�� �ee.l��+�� a�',�_-��iK�a�-Z. Cer►',e. t�-�
Plcase indicate the amount you are seel:ing in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �' Wou�e� ���L� �-� �2. tZi w-�b�✓�y3_c��v T-�'`t. c �S�'e��
� -L t . '(' v C c��. S' �e c ��
�'oFal ��g � °10�0
Vchicle Claims— lease com lete this section ❑ check box if this section does not a I
Your Vehicle: Year�_Make�Yle('�� Model C)
License Plate Number�l ���_ State�Color
Regis[ered Owner 11n�r,1.�.t1► �� ,rC,Su�
Driver of Vehicle c
Area Damaged �� '��Y�
Ciry Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
. In'ur Cl�ims— lease com Iete this sectio ❑ check box if this seetion does not �i 1
How were you injured?
What part(s) of your body were injured?
t
Flave you sought medical treatment? Yes No Planning to Seek Treatment (circle)
When did you receive U-eatment? � (provide date�(s))
Name o('Medical Provider(s): /
Address Telephone
Dicl you miss work as a result of your injury Yes o
When did you miss work? -- - - - - (pr�visl�siaicjs))_
I�1ame of your Employer:
Address Te c, hone
❑ Check here if you are attaching more pages to this claim form. Number of additional pu�es
I3y sigilliib�tltis form,yoce are stating lltat ull information yoce Itave provided is trice aitd correct to t/ze /iest
of your kftowledge. Ufasigned forms will not be processed.
Submittiiig a false claim ca�: reszclt in prosecutio�t. Date f'orm was completed
Print the Name of the Person who Completed his I'or �: m� �� ��v�"�
Si�nature of'Person Makin�;the Claim:
Revised Fcbruary 201 I
.�
Time:Llue ��,-���-,�-.,� I mVO1Ce �FL�o� (
Thursday,May 8,2014
10:58:36 AM
Michael Jackson
Ordered on
Thursday, May 8,2014
St. Pauf MN 55104
Workorder#29579
MAKE&MODEL F�EET NO. PHONE REP GSH PO# 7ERMS
2006 MERCEDES-BENZ CLS 500C HMED SO LS Cash
LICENSE NQ MILES IN/OUT VlN` TORQUE ENGtNE SIZE ' TRANSMISSION CO� R FRD DATE
MJEEZY WDDDJ75X86A012550 5.OL V$ FI SOHC 24V 4 SPEED AUTOMATIC
CATALOG DESCRiPTIUN QTY PARTS LABOR DISC FET TOTAL Code
SL Repair Wheel&Reseai 1 85.QQ $85.00 AS
'Repair from damage done on April 30th
Weicome, We appreciate your business. _
PAID BY Parts $0.00 Taxable $0•�
M1C$85.00 ' Labor $85.00 Non-Taxable $85.00
Freight $0.00 Local Tax $0.00
Other $Q.00
FET �o.00 TOTAL $85.00
Supplies $0.00
Paits andLatmr��b'es f�15 Ax90 days or4AGb�/es,whx:he�r�s first.Thzs waTantydmited fo lhe wHAr on U�is fam only.!/�mustb�2furnedlo ourshap ad custome/s expense,to hanor
warranly.thereby�fhoriae bae 2,aau xmik�be done ahng wr7h U�e necessary�lenaLs.You and yavemp�yt�es mayoperale�ha�ku,wi�sies oflesbng,rr�'vn aolg6Yeryaf mydsk An erqess
M�Chan�c?s 1'�n is a�h�wk�d on vehide!o secure Nre amnu�t o/iepairs fhe2b.You willrrot b�he/d rosponsrDfe to�bss ordamage fo vehtia�ora�s kBin hsh�de in case o/fiis,Me$aaa�enfvrany oMer
c�use 6eyond yvwcnnirol.Bacause ofMe extent afthe leartiown andmsqe�Gbn,t!�ishx:�may not perhrm as�as deAo2.No refunds on instal�d Tiies and or N�e/s,Sper./a/O�ieis ordiscanG'nued r7ems.
Allrelums a�e subjed k�15%ha�ad6rg cha�e.Anyde,vosils&2 subyectla ia�itifr nce/!ed
Prirrt Name Signature Date
Page 1 of 1
Pay Less Tires
698 University Ave • - ••
St.Paul,MN 55104
�m� ss�-ZSS-sa73 ` Invoice #24726
r��►$fl�
Wednesday,April 30,2014
9:49:49 AM
Michael Jackson Ordered on
Wednesday,April 30,2014
St.Paui MN 55104
Workorder#29408
MAKE&MODEL ` FL�ET NO. PHONE REP CSH PO# TERMS
MERCEDES CLS500 HMED SO LS ��
LICENSE NO. MILES IWOUT ViN TQRQUE ENGINE SIZE TRANSMISSION, COLOR PRD DATE
CATALOG DESCRIPTtON QTY PARTS LABOR DtSC FET TOTAL Code
AGWINMAX2453520 245/35R20 AUTOGUARD WINMAX 95V 1 94.77 $94.77 AS
CSB � Compute�Spin Balance 1 35.00 $35.00 AS
qyTg Wheel Weights 1 .00 $0.00 AS
RF Recyding Fee 1 3.00 $3.00 AS
TR13 Short Rubber Valve Stem 1 .00 $0.00 AS
Welcome, We a reciate our business.
PAID BY Parts $94.77 Taxable $94.77
VISA$140.00 Labor $35.00 Non-Taxable $38.00
Freight $0.00 Local Tax $�•23
Other $3.Q0
F�T $0�°° TOTAL $140.00
Suppiies $0.00
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Pti�t Name
SignaWre Date
Page 1 of 1
Pay Less Tires
698 University Ave � _ ���
��m� St.Paui,MN 55104
s'�,��: 65�-2ss�a73 Invoi�e-#24729 '
Wednesday,Apri130,2014
Michael Jackson 11:25:58 AM
�rdered on
St. Paul MN 55104 �Nednesday,April 30,2014
Wo�lcorder#29409
MAKE&MODEL FLEETNO. PW4NE REP ' CSH PO# TERMS
2006 RAERCEDES-BENZ CLS 500C NMED SO LS Cash
L1C€N�E N{? M�.ES ° `.1lIN. TCJRQU , �N(31
MJEEZY ' �►NSMtSSI{31�. COLOR ` PRD DATE
WDDDJ75X88A012550 5AL V8 FI SOHC 24V 4 SPEED AUTOMATIC
CATALOG DESCRtPT10N ` QTY PARTS LABOR `DISG FET ` TOTAL Code
SL _ Repair Wheel(Right Front) 1 45.00 $45.00 AS
Welcome, We appreclate your business
PAID BY Parts $0.00 Taxabte $0.00
������ Labor $45.00 Non-Taxabls $45.00
Freight $0.00 I.opl Tax $0.00
Other $0.00
F�r $o.00 TOTAL $45.00
Suppiies $0.00
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Page 1 of 1