Koehnen, Julia I
RECEI�IE� 5/20/2014
�iAY 2 3 2014
Dear City Of Saint Paul Claims Administrator,
CITY CLERK
I am formally writing to you as it is my intention to submit a claim to the City
of Saint Paul,MN for the damages that were sustained to my vehicle.The incident
occurred on April 11�, 2014 on the West Lafayette Frontage Road. I was proceeding
southbound on the aforementioned road and I hit a pothole that was in my driving
lane.There was significant damage to my vehicle including a damaged wheel,lost
hubcaps,suspension damage,alignment damage,and power steering-rack and
pinion damage. I have enclosed bills for the work that needed to be done. Law
enforcement arrived on the scene and by their direction a claim was submitted to
MNDOT(Minnesota Department of Transportation).MNDOT has indicated that they
do not have jurisdiction over this segment of road and that the City of Saint Paul is
the proper authority to submit my claim to. Please find the attached letter of
explanation from MNDOT. I am a college student and through no fault of my own,
my vehicle was damage by an improperly maintained road causing me great
financial hardship.
I very much appreciate your prompt attention to my claim.
Thank you again for taking the time to consider my claim,
��;��� ����"J
Julia Koehnen
3529 67�Street E.
Inver Grove Heights,MN 55076
651-324-2716
koehnenj 1102@gmail.com
I
RECEl�I�D
h1AY 23 20�4 '
NOTICE OF CLAIM FORM to the City of Saint Paul, Minn�� C L E R K
Minnesota State Statute 466.05 states that"...every person...who ctaims damages from any nwnicipaliry...shall cause to be presented to the �
governing body of the municipality within 180 days after the alleged loss or injury is diseovered a notice stating the time,place,and
circumstances thereof,and the amowu of comptnsation or other relief demanded."
Piease complete tl�is form in its entirety by dearly typing or printing your answer to eac6 question. V more space is I
needed,attach additional sheets. Please note that yon will not be contacted by telephone to darify answers,so provide as j
much information as nec�sary to explain your claim,a�the amonat of rnmpensation being requcgted. You will receive a
written aclrnowledgement once your form is recefived. The process can tske np to ten weeks or longer depending on the
nature of your claim This form must be signed,and both pages completed. If somet6iag does not apply,write`1V/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102
t ,/� �
First Namev u� � Middle Initial � Last Name t"u�h'e�
Company or Business Name
Are You an Insurance Company? Yes l� ff Yes,Claim Number? �
Street Address�J"5 a-� �0�+h S�' � I
City �hv���' ����s State����f0� Zip Code���
' Daytime Phone(� - Cell Phone �l SI ) 3� a���Evening Telephone�) -
Date of Accidend Injury or Date Discovered �IPV`� �1 1 � � � Time ��"�0 am/pm
Please state,in detail,what occurred(happened;,and why you are submitting a claim.Please indicate why or how you
f 1 City of Saint�a�1 or its e o ees are involved ana�or responsible for your damages. ` C�S �V�.��Y. 1�.
� � �owr1 w �f�,� �� �act caKSe ! 0.� awavt s .J
ct w f ri i . Sau�1 5 � 1 c a�ineab
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M�#{i`? d3 � W' - ( k't' aY�b ��'8f sE U,h�+
wn �' � Y N►a�I �',itlM ttr. a► rwW
�� (M ah.-rv� ct aF aun+ �a r t��.spe,n� rny �el�v �- � � v���c�- �
Please check the box(es)�most closely represent the reason for completing this form: �"�'�` b O I Y��A �'
❑My ve hic le was d a mag e d in an acci dent ❑My ve h ic le was d a m age d dun n�a tow
�'f 1�iy vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
��O My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other type of property damage-please specify
❑Other type of injury-please specify
In order to process your claim vou need to include cooies of all aualicable doeuments. i
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WII.L NOT be returned and become the property of the City. You are encouraged to keep a
copy for y urself before submitting your claim form.
�Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage eaceeds
$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;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O�njury claims:medical bills,receipts
j�Photographs are always welcome to document and support your claim but will not be retumed.
Page 1 of 2-Please complete and return both pages of Claim Form
Failurc to complete and return both pages will result in delay in the Landling of your ciaim.
All Claims—olease comalete this section
Were there wimesses to the incident? Yes No Unlrnown (circle)
Provide their names,addzesses and telephone numbers. �L��Y��
SYW �d�Y tV�
Were the police or law enforcement alled? Yes No �� Unlmown (circle)
� � �� � #or re rt# �
If yes,what department or a�ency. ��iil� �h-k�Q�1�1.� Case po �_�
Where did the accident or injury take place? Provide street address,cross street,intersectio � am+e f r�rk or f ility,
sest an etc. 1 �de '1 as po�si le. ff n sary,attach a diagam.
Please indicate the nt yo s ��n in com nsat�n w t you woul ' e C' to do t resolve this claim
to your �sfactio . �
, I .00 - reciP+s �� � ed
Vehicle Clam�s— lease com lete this seetion 0 check box if this section does not a 1
Your Vehicle: Year ` Make SU�UI�-t Model Y'�
License Plate Number Z� �} State_�Color �(N
Registered Owner I 1�1
Driver of Vehicle
Area Damaged � �'�
City Vehicle: Year Make Model _
� License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged -- --°
_ - .
Iniurv Claims—Qlease comolete this secflon ' �check box if this section does not annlv
How were yon injured?
What part(s)of your body were inj�red?
Have you sought medical treatment? Yes No Planning to Seek Treatment(cizcle) �
When did you receive treatrnent? (provide date(s))
Name of Medical Ptovider(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 attaching more pages to this claim farm. Number of additional pages �� . ',
By signing this form,you are stating that all informa�ion you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be prncessed
Submitting a false claim can r�sult in prnsecution. Date form was completed ��a�I ����
Print the Name of the Person who Completed this Form:�,�t 1�1111 W��f���
Signature of Person Malung the Claim:
Revised Febniary 2011
�
inneso�ra
DEPARTMENT OF ADMINIS7RATION
Risk Management Division
310 Centenaial Office Building
658 Cedar Street
St Paul,Minaesota 55155
Phone:651-201-2586
Fax:651.297.7715
TTY:651.296.6280
Apri122, 2014
Julia Koehnen
3529 67"' Street East
Inver Grove Heights, MN 55016
Re: D/L: 4-11-2014
File No.: GC116078
Dear Ms. Koehnen:
This acknowledges receipt of your claim. Under Minnesota Statute § 3.736 Tort Claims, our
office represents the state agency and all of the state employees involved in this matter.
We aze investigating this claim with the Department of Transportation.
Once we have completed our investigation we will immediately let you know. Please direct any
communicadon on this matter to the attention of the undersigned. Thank you.
Sincerely,
��
� t
;� �_.....
_.�/
Bryan Freeman-Sr. Claims Rep.
Risk Management Division
I
An Equai Opportunity Employer
�'
�
innesot�
OEPARTMENT OP ADMINISTRATION
May 6, 2014 Risk Managemeat Division
Centennial Office BuiWing
3rd Floor N.W.
Julia Koehnen 658 Cedar Street
St.PAUI,Minnesota 55155
3529 67�' Street East Phone: 65�.2o�.2ss6
Inver Grove Heights, MN 55016 Fax: 651Z97.7715
Re: Date of Loss: 4-11-2014
Claim No: GC 116078
Deaz Ms. Koehnen:
I have received a response from MN/DOT relative to the above-referenced claim. Under
Minnesota Statute §3.736 Tort Claims, our office represents the state agency and all of the state
employees involved in this matter. We understand you encountered a pothole while tra.veling
westbound on the Lafayette Frontage Road leading to T.H. 52 in St. Paul, Minnesota on 4-11-
2014.
MN/DOT states they checked the Metro Radio Log reports for the two weeks prior to and one
week after the stated date of loss. The log shows a notification call for this area on 4-16-2014.
This call was referred to the City of St. Paul.
Minnesota Statute § 3.'736 governs claims against the State of Minnesota and its employees. The
statute provides that claims may be paid in cases where the State or its employees were negligent.
In this instance there is no evidence of any negligence. MN/DOT advises they are only
responsible for maintaining the ramps in this area. If this incident occurred on the ramp, ,
MN/DOT had no notification of this pothole prior to this incident.
Since I was unable to establish that any employee acted negligently in this instance,the
Department of Transportation declines to offer any payment on this claim. From the information ,
presented on the Claim Report and Demand form,you may wish to contact the City of St. Paul '�
about this claim as they aze responsible for maintaining the frontage road. ,
Sincerel I
Y�.--�
... �
�L'����
Bry�man-Sr. Claims Rep.
Risk Management Division
An Equal Oppo�tunity Employer
CLAIM REPORT AND DEMAND
This claim must be filled out by the person making the claim against the State and/or its employees. It is to
be returned within 10 days to:
Risk Management Division
310 Centennial Office Building
658 Cedar Street
St.Paul,MN 55155
1. CLAIMANT
�u�, �o��r�er� � 352� 101�'�' S�� .
Name of Claimant Home Address
tl�0�,1 i°Iql �.���r�►C fl��� �N SS��
Date of Birth City,State,Zip Code
S1 �� c��-3a�—a���
Marita Status Home Telephone
����n �r
Name of Spouse Business Address
�bnS �r��A.(
Address of Spouse Nam' f Employer
� �r���-Pau�.� M� �s�o�
No.and Age of Dependants City,State,Zip Code
�'f)P�i1RX1��a �, Q�'q1'�lt�' �OYY� (�s�'_�"' ?��
Email Ad ��s �— Business Telephone
2. ACCIDENT OR OCCURRENCE
�}�Il ��b 14 ca m.� li='�9�`�'
Date Time
v��t � ��fi-e �n I� �un�- Par�-�., M�
Location City,State
Cl�l.r �f�t1'S z G�aYK-
Weather Conditions
Descnbe the accident r occ ce in detail: ���U �� �� V�
. -�'I�t . S
vl � �
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�arr�e So [ 5-1►11 �. � �l� � d C s��� �y�
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�, ��� �� � �nG���- —��, � �. c��--�- �.Q.
� �hiCl� .
�
Full names and addresses of all witnes"s�•
a. ��,Q,l��I�l�' �� Gl,L�
b.
c.
Full name and address of each state agency and each state employee whom you claun caused your
damages or injuries:
a. Xr
b.
c.
Full name and address of all other persons,companies,or govemmental agencies whom you claim
are respo ibl for yow damages or injuries:
a. �� P�oa�t�� oF�T�ans��'a��
b.
c.
State the cause of the accident or occutrence:
C lk � trlr�tX1,C� 1/�S �-�'1'�. lC(;�'
l�` .F-�x tn -}-t+� t�s
3. DAMAGES OR INNRIES
Full name and address of injured person on whose behalf claim is here made(hereinafter"the
injured"):
(If a minor,include birth date and parenis'names)
Full name and address of other person(s)suffering injuries,if any:
a. �
b.
c.
Describe the injury,damages and losses incurred hy the injured on whose behalf claim is made:
� N� �hr�.r�es. �
What was the injured doing at the time of the accident:
�
If injury or damage was to property,state in detail the foilo '
a. What was damaged: � g� �'I.
` ��,�t ��t.b t� dv�v�e. �t,sb
S'� 2 Vu�b
b. Name of manufacturer. c��.ti/1��
c. How old was it: ' �
d. What condition was it in at the time of the accident or occurrence:
srt�fi� `�� �a �.� -
e. Any prior damage:If so,descnbe: � �
f. Where pw�chased• �
g. If other than claimant,who owned it at the time of the accident:l. ra����
'�JV�.tG� a�" -f1�c, c� �.�d�-dt�"
h. Any liens,mortgages,attachments,security interests or third party rights or claims
outstanding on said property? If yes,state name and address:
�d
i. Estimated cost of repair. { �•
j. Where is the damaged pmperty now located: Q. ��
c�a�f c��- to t�i.o� � u� �s a-�-�c� � �'aw� in -�t'Pa�.�
If injury or damages were to the person of the injured,state the following:
a. Where was the injured taken:
b. Full name(s)and address of doctor first called or seen:
c. Full name(s)and address of any other doctor giving treatment or diagiosis:
d. Did injury arise out of or in the course of the injured's employment?
If so,describe:
Any type of insurance coverage protecting claimant for the damages sustained?
If so,descn`be the kind of coverage and company:
State the amount hereby claimed and de.manded by you from the State:� ��O i O�
t
State the basis of the calculation of this ount�6 � �r � � �. �� �`l'!G�
�ar �- 1�e.� �irt —�ioa.oa ��n c��, �i5+oo tn ��
�01acp ,�1P�'QVS ev► bt�J-�n Lc� -d�iv'�.s — ��5 ,� �.��!qppp
Have you made any other claims against the State and/or its employees?_ lV�
If so,state the date(s)and circumstances:
I hereby certify that the foregoing statements and claim made by me are true. I am aware that if any
statement made herein is to my knowledge false,in whole or in part,that I am subject to punishment
provided by law.
Dated: �����1✓
Si tnre of Claimant
I'ride,Professionulisrn&Partaers�ip
A• HU1�g
�ol�ce Offcer
P(?LICE DEPAR'TMEN�'
CITY OF SATM�PAUL '
. 367C.wrStRet Yoinr,Mm7:45/266-
900D ev71J107
���NSS ��
�j�
�Yo4 haYe qua��oL Y�iepo�,cai�
�PaM Pbiioe Aeeards Uet(631)2f6-57Y9
If you have a comment or concern about the service you
have received,you may report it to the$t.Pau1 police
�ePartment,the Civilian Intemai qffalrs Review
Commission,or one of the organizacions listed below:
Police Civilian Int.Affairs Review Comm.(651)266_5583
St.Paul Police Department Int.Affairs(651 j 266-576p
Nt1ACP(651)649-Q520
Council on Asian-Pacific Minnesotans(651)757=1740
Hmong I8 Councii(612)239-9526
Neighborhood Justice Center(651)222-4703
Neighborhood gouse(651)7gg_25pp
Indian.�f{�Council(651)296-p132
Saint Paul Hvman Rights(651)266-5900
Ali retums and warranty daims must
A��O 754 R�ce St be accompanied by�is original irnoice.
S�Paul,MN 55i 17 See reverse side for additiona�store policies.
PARTS PF X�6;����o • .
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SALES PERSON ORDER TYPE ' ` TAX.ID I COUf SHiP YIA ; PAGE ''
1 - 1 TSS COUNTER SALE MN 1
QIJANTITY DESCRIPTION IJNIT PRlCE EXT PRtCE
1 DEPOSIT $102.24 $102.24
W:52503
`�a�u�y �u�ed cuad e��,;c�tec��l'� sy�scc t�s�C �¢��vacl�e�
NOTES:
Ace is not responsible for TPMS sensor.
PAYMENT TOTALS: PAYMENT NOTES: TOTALS:
CHARGE FREIGHT
CASH $102.24 DISCOUNT
CHECK TAXABLE �•�
CREDIT CARD NON TAX $102.24
DEBIT CARD TOTAL TAX �•�
PAYPAL ALL MERCHANDISE SOLD AS-IS
RECEIVED BY: INVOIGE AMT. $102.24
._.�,......�_.w.,.�.
__ All retums and warranty daims must
AUTO 754 Rice St. be accompanied by this original imoice.
St Paul, MN 55117 See reverse side for additional store policies.
PA RTS Phone:(651)2249479
Fax:(651)293-0670 � � �
�eta,6lla�rid t�c 1'9P9 1NE BUY jUNK CARS� 525t13 4/14/2014 I�:25:39 PM
dCE-autoparts.COt11 Mon.-Fri.8 a.m.-530 p.m. • • ' • ► '
sales�ace-autoparts.com Sat 8 a.m.-1 p.m.
; 1
S N�� S Preferred Customer
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SALES PERSON 'ORDER TYPE ` TR�(1D/CODE SHtF VlA PAGE
1 - 1 TSS WflRK ORDER MN 1
QUANTITY D�SCRtPT10N 11NIT PRiCE EXT.PR{EE
1 560-72b881U-Wheel;Grade A $95.00 $95.00
R 001912643;VIN#KLSJD66Z66K482�1; PO#130062; Requested:20�
FORENZA;FORENZA 04-08 ro�d wheel, 15z6,steet; Q:1769203
Replacement Options For:56Q72688
None Available
1 DEPOSIT ($102Z4) ($1U2Z4)
°�a:��y �ored�d a�e�.ted—'7l�� yau�rve clazv���u���e!
PAYMENT TOTALS: PAYMENT NOTES: TOTAIS:
CHARGE FREIGHT
CASH DiSCOUNT
GHECK TAXABLE �-�
CREDIT CARD NON TAX S(1.U(1
DEBIT CARD ` TOTAL TAX $7.24
PAYPAL pLL MERCHANDISE SOLD AS-IS
RECEIVED BY: INVOICE AMT. $p,QQ
,., .......:_�..,.�
All retums and warranty daims must
AUTO T54 Rice St, be accompanied by this original tnvace.
SL Paul, MN 55117 See reverse side for additional store policies.
PA RTS PFhax(561)293-0670 �
. �
F,dta�6lta�c.d ta 1'929 WE BUY)UNK CARS! 987143 4/15/201415:02
lC@-autoparts.00111 Mon.-Fri.8 a.m.-5:30 p.m. • ' • ' '
sales�ace-autoparts.com Sat 8 a.m.-1 p.m.
; 1
s JULIA 5 Preferred Customer
� St. Paul,MN 55117 'H
u 651-324-2716 p
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SALES PERSON' QR�ER TYPE '�AX ID(CU�E SHIP VIA PAGE
1 - 1 TSS COtJNTER SALE MN 1
QUANTITY DESCRlPt70N UNR PRICE €XT.PRICE
1 568-726881U-Wheel; TROY A �95.00 595.00
R 001912643; VIN#KLSJD66Z66K482901;PO#130062;Requested:2008
FORENZA;FORENZA 04-08 road wheel,15a6,stcel; Q:1769203;W:52503;
D:275�471
1 DEPOSIT ($102.24) ($102.24)
W:52503; D:275471
1 �IRE MOUNT RIM 55.00 $5.00
W:52543; D:275471 _ � ___.
1 TIRE BALANCE $10.00 $10.00
W:52503; D:275471
� �
��+� �v�a.ud a�r��cutec�'7�� y,a�c�a�C ���'
NOTES:
Ace is not responsible for TPMS sensor.
PAYMENT TOTALS: PAYMENT NOTES: TOTALS:
CNARGE FREIGHT
CASH DISCOUNT
CHECK ' TAXABIE �.�
CREDIT CARD $15.00 NON TAX (��•�)
t3EBiT CARD ' TOTAL TAX $7.24
PAYPAL ALL MERGHANDISE SOLD AS-IS
RECEIVED BY: INVOICE AMT. $15.00
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` 1� RICE ST,
�INT PAI�. �N�I 55111
6�1-�14-94]9
Terminal ID� 00645612 0003
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MASTERCAHD
AOCT #: x�+��*�x��*��8592
C�DIT SAIE
UID: 410�411�92 �F #� 6833
BATCN #� 359 AUTH #� 006833
NMOI�+it $15.00
APPROVED
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POLICIES ON EIECTRICAI � Fl�l
REINTED P�RTS & F� tRA�iC11 c�S
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Cl�TO�R C�'Y
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���.�� 5/05/14 6147982/
(661)451 1313 g�p��i��
��"� ��a'"-�D�30p-m- 5/07/14 Pre—Invoic
r-aoc(65t)2�1-82es �Aa�►-Sa1ud�►
��"''isT°'"�' 61639 61648
NATS F./4390
.
3529 67TH ST. S 651-324-2716 RLSJD56Z18K851466
INVLR GROVS H$IGHTS, I�+II�T 55076
651-457-3395
2 0 0 8 SIIZDKI FORffiiTZA 4DR SDN AD'I'O
1 - : P RM CO Y $ N
LOW TIRE PRESSIIRg LIGHT ON?
Work performed by SS (166)
Sub Total: .00
- ------------------------------------------------------------------
#2 -_147495 z �BTIl� 2 WHBgI, p1LIGNM�NT$�4.g5 CpIIppN SPBCTLT•
_-- HAD TO REPLACE DRIVBR FRONT TIRB
"¢�f�forme�d by SS (16 6) 74.9
ALIGNSD FRONT END.
S Total: 74.95 --- - - ___— ----
-----------------------------------------------------------------
#3 - 012195: BPRBSS LIIBB SffitVICS $21.95 COIIPONiJP �O 5 QTS.
NON SYNTHSTIC OIL
Work performed by SS (166) 10.23
Inatalled lAMFL00002 :FILTER: ENGIN$ OIL 1�5.40 5.4
Installed 68055890AA :OIL: 5W20 5e3.13 15.6
Hazardous l�aterials Charge 2_�
CHANGSD OIL AND FILTER.
Sub Total: 34.03
--------------------------------------------------------------------
#4 - 02S: STSI�RING /SIISPffi�TSION RSPAIR
RSPLACE ST�RING GBAR
Work perfonned by SS (166) 317.8
Installed PS 361823 :GSAR, POW�2 STSSRING 1�475.99 475.9
Installed ATl�i 1003617 :TIB ROD BND 1Q44.99 44.9
Installed ATM 1003616 :TIB ROD ffiJD 1@44.99 44.9
Installed 68055894AA :FLUID: ATF + 4 1a9.50 9.5
RSPLACBD RACK AND PII�TION AND OVt'!3R TIB ROD ffi�IDS, F
.SiRlCTLYCI18F1 lRiE33 ARRANGHIBlTS ME IMOE. �hsaby a�lwize f�s iap�ir L.AHOR
h�b bs dons dag�fr naos�aar mrryl ad ap�s trt yau are not�eapa�a-
iar lo�ar dOm�g�b vdiefs at ifeNs Mt la Ne vMicle in Ci�d iR�eR ar sy arr► P��
Esyoed yaur oaial v tar an�dd�s eaisad by ar��6Ry d P�IS ar AM�ys in�ps p�UCT�L.E
bY IAS at4Pis ar taroponer. �he�bY 9�Ya a��PbY��b
9�s vancM hs�in dwubd on sreMs.li�Nnys,or ella�M�Me tor h ptq�ass d tetig �UBIET
N�sp�tlOn M apwss aieclrNC'�Mn is Iwabp ado�orAsdysd on abasralikL b leaw
araoint d iapeYs IUsMa• 8110P St�PLES
OF wAliitAttilE,B. Mry wartaM m t�e P�sold As�by w twoe awde yr FIAZARDOOS�AII7EWAL8
m�riecYss'1tK salw nsaby�wehr�delws all wpawes aMwra�ass ari�plbd, SALES TAX OR TAX I.D.
a�f��Pwd�h d��1�6i1Y a►QSees for a psYaYr pupo�s,sd Oe aarer oelier
nar s�wixas any ofis pasan b saaee for k anp Yb�r in oo��e�fm rMh t�s a�e d �AL ORDER 0�'0.91T
p�oduels.My ioif�on na�M�6�ed Aeiain doea�at applyMie�e pd�lieA bY Iwr. p�g .
TOTAL DtJE
X �_ ` � -i G't���
��,�� 1000 S.Corx�ord Street
sa�h st.Paul,MN 56075 5/05/14 6147982/
(651)451-1313 g�E p��Hp�,g
1-800-�6-0028 7:00 a.m.to 5:30 p.m. 5/0 7�Z 4 Pre—IIIVOl.C
Fax:(�1)251-8266 MondaY-Sacurday
a1p�+n..�T.P� """�"fi'�°�'�" 616 3 9 616 4 8
NATE F./4390
, A
3529 67TH ST. T 651-324-2716 RL5JD56Z18K851466
INVER GROVE HEIGHTS, MN 55076
651-457-3395
2008 SUZOKI FORENZA 4DR SDN AiJTO
ILLED AND BLLD SYSTEM.
Sub Total: 893 .35
--------------------------------------------------------------------
#5 - 025: STESRING /SIISPENSION REPAIR
REPLACE STABILIZFsR LINKS
Work performed by SS (166) 101.1
Installed NCP 2651628 :LINR, SWAY BAR 1�49.99 49.9
Installed NCP 2651629 :LINR, SWAY BAR 1�49.99 49.9
REPLACED FRONT SWAY BAR LINKS.
Sub Total: 201. 12
--------------------------------------------------------------------
#6 - 08E: ELBCTRICAL REPAIRS
INSTALL LLFT FRONT TIRE PRESSIIRE SENSOR, CURREN'1'L'Y
HAS REGIILAR RIIBBF'sR STEM
Work performed by SS (166) FixltFund
Installed BR 923304 :TPMS FixItFund
REPLACED RIIBB$R VALVE STffiK IN LEFT FRONT TIRF WITH
TIRE PRESSIIRE SENSOR, ROAD TESTSD, IINABLE£ TO FIND
PROGRAMMING INSTRIICTIONS IN ALLDATA. REC. TARE TO
SUZUKI DEALER FOR PROGRANIl�IING.
--------------------------------------------------------------------
MANAGFsR'S DISCOUNT -120.8
*************************************************�**********
* FREE LIFPTIME TIRE ROTATION W/PIIRCHASF3 OF 4TIRES. *
* LIFFTIME WARRANTY ON BRAKE PADS/SHOLS/SHOCRS/ *
* STRIITS/FRONT II�iD ALIGNMFNPS. MQTORCYCLES * '
* EXCLiJDED.GUAR.ANTLED PRICffiK1�TCH-WE SLRVICL ALL *
* MAKTS&MODELS! *
*************�x**********************************�***�*******
w�s:srnicnr cas�+u�ss ar�nrx��rrts n��. h ne�ny�m�� u►aoEt 5 0 4.2
n��►m�a���a,n,e��r��+a�n,�►�,��a�- PARTS 6 9 6.5
'ble for bss a damage to vehide a artides IeR in tlie vehide in case af f�e.Mefl.or any otl�er . O
e beyorM your conbol or tor anY ddaYs�bf'�Y�P�a��P� DEDUCTIBLE
F�m�ts bY tlie suPP�iet or§ansPater. �herebY 9raM You u►Sra►�ploy�s P�m�sion to . O
the vetrde herein descri6ed an streets.highways.or elsewitiere(or Vie purpaae d tesUng SUBLET
a�r�sp�tion. ao e�s�s�n is rrereny aacrawieayed oo�e v�aae�seaxe sHOP suPPL{ES 2 0.0
amamt of repeirs tlrereto'
HAZARDOUS MATERUILS 2 .7
�oF wn�s. a�y w�es o�a����ow►�my s��maee by 51. 0
e manufaaurer.The se�r hereby expressy disdaims�1 waranNes eilher mcpress a imqied. ^aALE3 TAX OR TAX I.D.
�9�Y impN�wartaNy d me�d�bdily or fitr�ess for a pardaYSr pwpose.�d the se�r�eiU�r .�
���mw���r o�r+�ro��ra n�,y u�r�o�,�mn n,e�a SPECtAL ORDER DEPOSIT
� �oa�s.n�y��ne�,aoes�a aapy wi,«e aarama br�- ��sCOUNTS —12 0.8
TOTAL DUE 11 3 .6
X
FURV hOTORS
10�9 S CONCORD ST
SOUTH SRIN1 PRUI MN 56875
651-451-1313
eees
Ter�inal ID: 8@684858 __
-------------------------3:23 PM
5�7i14
pnERICf1N==isi=�aaai1884
pCCT n�
CREDIT SRLE
UID: 412Z29961944 REF a: 3968
BATCH M: 2Z6 AUTH M: 517835
arouaT 51163.sz
pppROVED
NWN.FURYMOTORS.COM
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