Cartharn ,
RECEIV�D
I�AY 0 9 20�4
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes�aTY CLEI�K
Minnesota State Statute 466.05 states that°...every person...who claims damages from any municipality...shatl cause to be presented to the
governirtg body of the rrcunicipality 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 provide as
much information as necessary to expiain 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 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�� T��� Middle Initial Last Name ��,4 1� �"���1'�I�
Company or Business Name
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Address���'L� ����y�' r cl ����
City �i 1��i�`>��C��� State I l�r1 Zip Code - �� ��..;�,
Daytime Phone( ) - Cell Phone(�P��)�- c � Evening Telephone( ) -
Date of Accident/Injury or Date Discovered '�1-'� � - �� Time . �'��� am/�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please i 'c�i�why o1�w you
feel t�ie City of Sa�� t�P ul or its em loyees are involyed andior responsible for your damages.
f�S����" ��1-��.,� Q� �� iulQ+���l � C;t�+►'1 O Ci.f�C1
Please check the box(es)tr�:���:c?�ce'-;�=eYreser::-"•e=�ws�"f�-�`�""y�`�:"b�"�=�f�=�"'� .
0 My vehicie was da*!!�ge!�in an arrirlPnt ❑ My vehirlP tuac rlamaoP�� ri�����ia a fnz��
o-- o-- -`
�'My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
� .,r.,.��;�.�P�.,�� . ..��i��:?;:o.�,�.a-��,a��r t:�'.:Pted � z.,,as i.^.jured on City property
C (,.;.,.� ��Y^.,r..... .,
.���,.,� tyt.e��f,�.,t,c��y ..a�,�age-please specify-
❑ Other type of injury-please specify
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In order to process your ci�r�� �VLL lIGGLL Llt 1l�������� �Vl��`-^���! n!� n������`"n����!!Ubl�!!t��! �e
-t_'�_ .L_ �'___"""`.. [' J•__.�.1 ' '�� -�
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`:- � ,.. . _ ..�-„ �ic.i,iw.,i�cn.,c ��c.,�,�G l„ „�..,�.i.,G�UG,,.q.,,�,�c,l�., ,�a_,,.,n,c�±,_,l ,l wi �i.elay the han mg o
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c,.:��_,. ;;1,j,,�_______ii� rris.i.ivvi vc iciuiiicu diiu vc�viiic uic YivYciiy'vi uiZ�;ty. ��u����i��u�aged to keep a
copy for yourself before submitting your claim form.
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��D�.i�.yuniunr_.,:.......... ... .. ..,,...,... ,..,. .,,,.......,-..,. .... ..... . � ..... .. ... �
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.pSOO.Qv, Gi iu�a�.�.uu, v,uo u�iw.., ,..w,l„..,.., .,,..,,..t,.....,
at,.. '
O Towing claims: legible copies of any ticket issued and a cai;y of t,�irl;�,���ii� 1��i���i�,�
nn«i..,._.....,...,. .. a,......�,. ,.i.,•...,......,._,............ ........,,,. :ra.,, a,...,,.v,. ,... ,.a.. ccnn n:.; ,. .t.., ��t„�1 1J:I1S
--- - -..:.... '_.. .:-.--. . _.,,..._... __:�__....._.,. .;f�amaged items
-- ......
----•--- —---r-- --- ---- --r----,
n *--: -�- ���.:::s• :::e�?ical bills,receipts
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.�:..j .. • � ' : ,'1: .�..� 1:.- r.�hirnar�
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Page 1 of 2�P���.,....... -`�:..»��_�::._..�:;�: -- .._.., ���-.._�__..--�
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please comqlete this section
Were there witnesses to the incident? Ye �' No Unknown (circle)
Provide the� names,addresses telephone nu bers: a��C•!'l 'u t- 1�1c��'/1
�I tL �� �.�K.� c�:v ;� 1 .> �r��1� � �a ���► -��L-r�
Were the police or law enforcement called? Yes � 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. MC�.r�O{1 4. L.v�'►��
C�►t�C� - --
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year qG q Make Model '� 1 l:�t; �P �
License Plate Number� State,�Colar Gt C it
Registered Owner �' �� � r '_
Driver of Vehi e P ' r ' -�-�`l
Area Damaged � (l
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section '�check box if this section does 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 attaclung more pagesl,to this claim form. Number of additional pages
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 resu�t in prosecution. Date form was completed�'u�' `�
Print the Name of the Person who Completed this Form: � `������r
Signature of Person Making the Claim: ^�
Revised February 2011
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SOaQER �EEL ALIGNMENT, II�C.
FRONT END 8 STEERING SPECIALISTS • COMPUTER HIGH SPEED WHEEL BALANCING �
� DOMESTIC • FOREIGN • TRUCK . RECREATIONAL VEHICLE
La
COMPLETE BRAKE WORK
207 Lowry North MINNEAPOLIS, MINN. 55411 Phone 612-522-4489
NAME�� r''.
P��� -
ADDRESS� __ PHONE —
�A..T� f /� M j NS`�N�. ___ 5 MI . „ �
,�;,,-*�. �� �/��� '� !���f� � ,f� �`^l d� 'r �. fi�t� � I t �- ,t'.y
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� ESCRIPTION OF WORK ' `1 AMOUNT
QUAN. PART NO. NAME OF PART AMOUNT -
WHEEL WEIGHTS `' WHEEL � 'G'' "�'
! BRAKE PADS SPRINGS
BRAKE SHOES BALANCE WHEELS
SHOCKS SHOCK ABSORBERS
MaPHER. STRUTS TIRES ROTATE
/ BALL JOINTS STEERING GEAR
TIE RODS ,�.0 IDLER ARM �"�;, � .� .!!_ /=' '=' �'"
� IDLER ARM � � �" TIE ROD ENDS
�,W 'cn
, CENTER L�NK CENTER LINK
PITMAN ARM ,�,' BAL� JOINT �� �'.� �„ � ,.�.r 1 ��' '' ``_
. I
y�,r � l>f�� � /� �' . PACK FRONT WHEEL BEARIN
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�--�—� ,,� SUFIFACE ROTORS _
V SURFACE DRUMS
--- - I
---�- CALIPERS
- INSTALL STRUTS
PITMAN ARM
- --I --- ---- -- - - �,, r � `�°` � ��: �:�..�
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ATT: R�TORf�UE '�
LUGNUTS AF7ER ----
100 MILES ON ALLOY WHEELS
TOTAL PARTS b TOTAL UBOR 4"` °
---- TOTAL PARTS � '�' �'
ESTIMATES FOR LABOR ONLY- MATERIAL ADDITIONAL