Holt, Aimee �Ct�G�UC�J
MAY �72014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne�ql� �����
Minnesota State Statute 466.05 states that °...every person...who claims damages from any municipaliry...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 amoisnt 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 explain 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 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 �YVl�,�i Middle Initial L Last Name ��"�
Company or Business Name I v��
i�Are You an Insurance Company? Yes No If Yes, Claim Number? �' �
Street Address ��'� � ►"�r I-S �Vl� �'11�� �
City ����5`� ;��` ���1 � State �N Zip Code J�� � �
Daytime Phone (�P�J�) I�-�I` g Cell Phone(�)��g5- � � Evening Telephone(�O�J_)�`��- �1���
Date of Accident/Injury or Date Discovered ��'� 2�' I� Time 7 3� rr il pm
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 our damages.�S --�- �vCS
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Pleas check�(e box�(es�that most clos y represent t e reason�or comp`leting this�ar� � �����,��,I t- j 1�
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged durmg a ow ��
�My vehicle was damaged by a pothole or cor.dition of the street ❑ My vehicle was damaged by a plow
❑ M y vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property S�t��t'
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you 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 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 andlor 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; or 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—Please complete and return both pages of Claim Form
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 the incident? Yes No Unknown , (circle)
Provide th ir names addresses and telepbone numbers: L�( � 1 C�l5 �i� � " l 'S
� �� � r - _ -�_ ,_ _
Were the police or law enforcement called? Yes N� Unknown (circle)
If yes, what department or agency? �1Y'� Case#or report# Iv f{�
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 dia ram.
�� ti'c�� �� S�'� . . v e � � S �. , � e� ,vt Pv - . , fl �,�/C,�����
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Please indicate the amount you are seekin in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � .3�0,U��
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year G�G Make C' �O Model � C,� � — �`
License Plate Number D D State M� Color �V1 �G
Registered Owner �(yi�.(� I�U.i S�_ }-�Cj��-
Driver of Vehicle��y�l ��' Lti�i.1,�� �� �-��-f-
Area Damaged �� . �- �• bi, � �`` — �' '' i � -�L1� �2���j��IV��v�'�
City Vehicle: Year t.l/+�- Make ' ' Model i� ��-
License Plate Number r�;.�,� State��Color f�/�
Driver of Vehicle(City Employee's Name) ���A
Area Damaged �/�
In_iurv Claims—please complete this section � check box if this section does not app�
How were you injured? �i%A
What part(s)of your body were injured? j� l Fk
�
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? �;/J� (provide date(s))
Name of Medical Provider(s): N{�
Address N �fa- Telephone
Did you miss wark as a result of your injury? Yes No
When dic�you miss work? ��{� (provi�date(s))
Name of your Em loyer: '
Address hd�t� Telephone " /�
�Check here if you are attaching more pages 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 result in prosecution. Date form was completed �/�5 ���� i'T
Print the Name of the Person who Completed this Form: ���� L ���
Signature of Person Making the Claim: l ,e'2�_�
Revised February 20ll
CHEROKEE SERVICE osio2izoia
815 DODD RD. Invoice#
�+ . ���'�,��"�'' WEST ST. PAUL MN, 55118 5897
, Phone: 651-457-4722 M-F 7:00 AM to 5:00 PM
���'�.�1�� Thank You For Choosing Cherokee Service! sat-sun Closed
INVOICE
Todd Holt 2000 Volvo V70 Sitver
275 Christine Lane Odometer In: 125664 Odometer Out 125664
West Saint Paul MN,55118 License: 1AD204 VW:YVILZ56DXY2708292
Part Description Qty Sale Extended Labor Description Extended
Front Strut Mount SHOCK&/OR STRUT ASSEMBLY-Remove& Install
2.00 $11�.99 $227.98 or Remove& Replace- Both- [DOES NOT include
Front OESpectrum Strut align or bleed brakes.]
2.00 $105.85 $21 1.70 $223.20
Front wheel alignment
Road test vehicle. Check all suspension $69.00
__-----'"�,�
� and steering parts for wear. Check tire
� � �� �' pressure and condition. Check ridin�
�; �� �'��,...t<<.
� ,""'' ��,_...-- ' height. Check caster and camber
—;;� angles.Check and set toe-in as
�"� _� required. Center steering wheel.
pate �----'��
Service Advisor.Gouette,John Labor Total: $292.20
Technician(s): Ebensteiner,Adam Parts Total: $439.68
Sublet Total: $0.00
I consent to receiving text messages regarding your services,via automated technology,to the cell Shop Sup.: $9.32
phone number you have on file.I acknowledge that I do not have to provide this consent to receive
your services.Message and data rates may apply. Respond STOP to any message to canceL HaZM3t: $6.19
-------------------------
Sub Total: $747.39
Tax Total: $31.99
I hereby authorize the above repair work to be done along with the necessary GCatld TOt3�: $779.38
material and hereby grant you and/or your employees permission to operate ' BalanCC DU0' $779.38
the car or truck herein described on street,highways or elsewhere for the �
purpose of testing and/or inspection. An express mechanic's lien is hereby - �.;�,�
acknowledged on above car or truck to secure the amount of repairs thereto. �(�?ix,�',�rmm�°�Y��I��
Warranty on parts and labor is one year or 12,000 miles whichever comes first.
YOUR REPAIR COMES W1TH A NATIONWIDE WARRANTY(800)457-0019.
S[GNATURE.............................................................................................................. Date.............................................................................
_ __._. - -- ----
__ ____, — ..-- -----. _ _....._----- — ---__ --
, ,—__ _----
CHEROI<EG SERVICE j CHEROK�E SERVICE ; i CHEROKEE SERVICE
:
I $89.95 ' $189.95 � ' $19.95
�
, ; i
�i Coolant Flush � i Trans Flush i � Oil Change
' U to 5 ts Conventional Oil)
i (On Most Vehicles) � j (Synthetic) � � ( p 9
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� Coupon cannot be used with any other coupon or li i Coupon cannot be used with any other coupon or I I Coupon cannot Ue used with any othe�wupon or !
� discount.Limit one coupon per transaction. ; i discount.Limit one coupon per transaction. ; i discount Limit one coupon per transacuon I
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�i���,, { � www cherokeesvc.com
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CHEROKEE SERVICE )
815 DODD RD
. W 5T PAUL, MN 55118 �
(651)222-1634
05/OZ�2014 15:56:42
Merchant ID; XX�0000000(2519
Device ID: 5654
Terminal ID: PD061.
CREDIT CARD
VISA SALE
CARD# X)0000000000(5509
TRANS# 012
Batch#; 1
ApprovalCode: 755913
ACI Code: E
TRANSID: 084122791337249
Entry Method: Swiped
Mode: Online
SaIE AMOUNT $779,38
CUSTOMER COPY
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