Kinney RECEIVED
MAY �8 2014
NOTIC� UF CLA�IVI FaRM to the City of 5ain��uY.I,�V.[ffnesota
Minnesotu Stare Statcrte 4bb.05 states that °...every persnn._.who claims damnges fro�T:ar�y municipalit,y...sha!/cairse to be presentet!to the
�overning botfy vf the municipality withiR 18D days after the nlle�,ec�loss or injcrry is discovered a notic•e stating the ti�ne,place,and
circi�sirstances thereof,and tke amount of compensation or other relief demanded."
Please complete this form in its entirety by dearly typing or printing your answer to each questiun. If more space is
needed,attach additionai sheets. Please note that you wa'll not be contacted by telephone to clarify answers,so provide as
much i[tformation as necessary to explain your claim,and the annount oC co�npensation being reqaested. Yoa will receive a
written acknowledgement once yowr foxm is received. The procrss can take up to ten weeks or longer depending on the
nature of your ctaim. This form must be signed,and both pages completed. If something dces not apply,write`N/A'.
SEND COMPLET�D FORM �.ND OTHER DOCUMCNTS TO: CITY CLERK,
IS WEST KELLOGG BLVID, 310 CITY HALL, SAINT PAUL, MN 55102
First Name,��10-�UA Middle Initial T�Last Name Y-�1 (11'L�C�•.�
Company or Business Name
Are Yoa an Tnsurance Company? Yes/� If Yes,Claim Number?
Street Address �� O 1,� tCv'�—
City �0.., �W l(1 State �"��S LCX1,51(� Zip Code���o�
Daytime Phone 1( IS )a�3- �43SCe11 Phone C7i5 1��3 0�135 Evening Telephone(1�)o�a� O H3S
Date of Accident!Injury or Date Discovered M� i a, a o�y Time 1(�_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.F���maC{ �vt� E
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c,� s? 8d-'S���l �b��C�e..�N,.i� ;nc Id�e,r�t-."�i cti-� liwbc_� �a.f�__ c�b_ivKx,�-,o�,s-/�-
! -��nr L.�S'�n,�.t�i7'�L� n l�. ,• �'.l `�'L.a__r�ir�c 7� r nu l Es t_ [�'Sr �L�1^+��s c '�'O �(�/�+V �/f.�4(�L.
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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 ttte 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 injuzy take place? Provide street address,cross street,intersection,name of park or facility,
closest landmarlc,etc. Please be as detailed as poss'b1e. If necessary,attach a diagram. k;�1 nno��_ � E
.Z n �ir1'�' n C��'�n�t. C�M S�' �
Please indicate the amount you are seeking in compensation or what you would]ike the City to do to resolve this claim
to your satisfaction.
Vehicle Claims—nlease com�olete this section ❑check box if this section does not anplv
Your Vehicle: Year r�OUy Make SC�iJ(�'1 Model =-on
License Plate Number x State W-Z Color�k�,[.,�L
Registered�wner O�X� � �
Driver of Vehicle � M
Area Damaged �i r�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicte(City EmpPoyee's Name)
Area Damaged
Tn iurv Claims—pleASe comp[ete this section ❑checfc box if this section does not apply
How were you injured?
What part(s}of your body were injured?
Have you sought medicaI treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s})
Name of MedicaI Provider(s):
Address Telephone
Did you miss work as a resuIt of your injury? Yes No
When did you miss work? _ (provide date(s))
Name of your Employer:
Address Telephone
�1 Checic here if yau are attaching more pages to this ctaim form. Number of additional pages�.
By signing this form,you are stating tltat alT infdrmation you have provirled is true and correct to the best
of your knowledge. Unsigned fornas will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �� �0�0��
Print the Name of the Person who CumpleYed this Form: m 1r1f�1C�0. `�\'C�'{.J�
�
Signature of Person Making the Claim:
Revised February 201 1
TMS TIRE & AUTO
1501 COULEE ROAD #140514042 Page 1 of 1
5/14/2014, 8:48 AM
HUOSON, WI 54016
(715) 386-1560
-------------------__ - -------- — -- --- -- - - --__
AMANOA KINNEY - -- - - -- -
HOME: 715-222-0435 2004 SATURN ION
736 HWY 12 � 1 {wi) -
HUDSON,wi 54016 ACCOUNT#: ODOM IN/QUT: 196284 I 196284
Q000000004Z174763
- 2.O1,
--- --- - ,_
___ - -- -- -
__-- . _ _
- Sales Person: 102
Item Number Lx � �Descri_ _ �------�-
- --- —
- — -— --- -----
-- -�---------------�-------- —--- --ption _— ST ' Each _, Misc Extended
TIRES--The following items are 3uggested: " T
_ 1 i 7d6180034 _____L__T`GOODYEAR EAGL.E l.S 205/55/i6 ICO . 108.99 i ' 108.99
— �_— __ ,
---=-----
__-__----__-_--_--_-_-_—__ _ ub-Total Su��ested TIRES: 908.99 0.00 108.99
- ---------------------------------
Total TIRES: 108.99 0.00 108.99
�tequfred Paris 0.06
Required Labor O.QO
Suggested Parts 1 Q8.99
_ Suggested Labor 0.00
Sub-Total �� 108.99
State Tax 5.99
-- -------------—_ ----_T.
Grand Total 114.98
THANK YOU FOR YOUR BUSINESS, PLEASE COME AGAIN
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�ereby authorfze the repairs shown on this admate to be dme alonq with the necessary material and►�ereby 9rant Yo�and/a your employees permissbn m operate the vehkk herein described on streets,
�hways or elsewhere fa tlie purpose of testlnq and/a inspectbn.M express mechanks tlen is hcYeby adcnowkdged on above vehkle to secwe the amo�t of repairs qierto.We arc not responsibie for unavailability
parts a delays In parts stNpments beyaid our crontrd,nar fa bss or damage M vehkk or artkks 1eR In vehicle in casc of flre,theft a any othe►uusc beyorxl our[ontrd.
CUSTOMER SIGNATURE
5/14/2014