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Lewis, Wesley- -�--� ��C�i���� � MAY232014 NOTIC� OF CLA�M I'�RM to tlle City of Saint Paul, ���,e��RK Minnes��tct State S?atute 466.05 states that "_..every person...wfto clnims dnmages fro�n nny�municrpalit>>...shall cnicse to be pre.rented to the go��ernfng body of t!re»it�nicipaliN x�ithin 140 dcris nfter Ihe alleged loss or injitrv is discovered a notice statin,�tlte ti�ne,place,nitcl circunrstaitces ti�ereof,an:f tiae a�rtount of cotnpensatinn or other relief ctetnanded° Please complete this form in its entirety by clearly typing or printing your answer to each qeiestion. If more space is needed,aitach addidonaI sheets. Please note that yon will not be coniacfed by telephone to clarify answers,so provide as much information as necessary to explain your r_laim,and the amount of comgensation being requested. You will receive a written acknoivledgement once yottr form is received. The process can take up to ten weeks or]onger depending on the nature of your ciaim. This form must be sibned,and both pages completed. If something does not apply,�i�ri#e`N/A'. SEND COMPLET]CD FORM AaND OTHER DOCUM�NTS TO: CITY CLERK, 15 W-EST KELLOGG BLVT3, 310 CITY HALL, SAINT PAUL, NIN 55102 First Name �eS�e�! �.��.�1�S Middle Initial�Last Name �-2W+ S Company or Business Name /Vl�' Are Yon an Insurance Company? Yes� If Yes,Claim Number? _ _ Street Address / y�S �o�lS}y S f' L✓ �'P}', �L�g City State /'//V Zip Code �7 S 1 a�� Daytime Phone �Cell Phone(��•;}�Sh Evening Telephone(�)o�o?�S� Date of Accidend Injury or Date Discovered��t y I�� °���`'� Time .3a am Q i'lease state, in detail> what accurred (happened), and why you are submitting a claim. Ptease indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible for your damages. I�t,�„f fJil��-.r. �o A- �. Do s � f1; � �d . �, r� G �� �1-� " a�, v•� l� c��► �� .� f' L i r:� d- �- shao� a-� .Sct M M /'04� f7 S% �./ c%e�. !ru�d� n., r ; G•�ul � .•, . L./ht o� l, n+ C�o/�ed �' e. ( �d � hw k 6► G�•1 2�v �'t � � ,� ;. 6�cr a� �, t ol�- ,h car -1-� ' u,. f- �.. �v A (� t�t,lc..!_ �r��__�ht�/ �Le d �-,e, �-L- - �o� �w "�h�P► ' ul lf.wC t� tt �/ o.S M Ot� S 7 Li7�}� Please check the box(es)that inost ciosely represent the reason for completing this form: �y�' ❑ iVly vehicle was dama�ed in an accident ❑ My vehicle was dama�ed duzinb a tow �My vehicle was damaged by a pothole or condition of the street ❑ My vehic}e was damaged by a plow ❑ My vehicte was wrongfully towed and/or ticketed ❑ I was injured on City property O Other type of property damage—ptease specify ❑ Other type of injury—ptease specify In order to process you: claim vmu need to include conies of all appIicable docuznents. For the claims types listed below,please be sure to incIude 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 ta a vehiele: two estimates for the repain to your vehicle if the damage exceeds $�00.00; or the actuaI bills and/or reccipts for the repairs O To�ving claims: legible copies of any ticket zssued and �copy of the impound lot receipt O Otf�er proPerty damage ctaims: two�epair estimates if the damage exceeds�500.00; or the actual bills and/or receipts for the repairs;deta2led]ist of damaged items O Injury claims: medical bills,receipts � � O Photodraphs are alw�ys weJcome ta document and suppott your cl�im but will not Ue returned. Page 1 of 2—Piease camplete and return both pages of Claim Form Faiiure to comptete and return I�oth pages will result in deiay in the handling of youc claim. All Claims-please complete this section Were there wimesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: �'sh�e�i��,��7: aDfvS 41�eelU� ��-�_Soir,f'�j �►c� c f, ��•�x f��w�� $So�r3 Ph�ti� �1�3537��� Were the police or law enforcement called? Yes No Unknown (circle) If yes; what department or agency? Case#or report# Where did the accident or injury take place? Provide stree[address,cross street,intersection,name of$ark or facility, closest Iandmark,etc. Please be as detailed as possible. If necessary,attach a diagram.�-�!� rh!/� R�_ -Sc�w��j 3GtS�'�G,s�- �%1/'H.'1� �,vp :t G�$�rd o`ff Se,�6� �v�o. Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your sati1sfaction. �le..(tSE: �ei�h(,uiS G -�.� c�s�}- � �ey �}-:�/t, �kc� I.W�f r(ni n�A� Vehicle Claims- Cease com lete this section ❑ check box if this section dces not a 1 Your Vehicle: Yeaz Dt Make po y� Model I�a/� License Plate Number o�� YL '� State�Color L��nJe Registered Owner �� 1Gti/ �i.rh S Driver of Vehicle 1�c�s�e� �w.S Area Damaged -H/�-� City Vehicle: Year��_Make Model License Plate Number State Color Driver of Vehicle(City EmpPoyee's Name} Area Damaged Tn jury Claims-p�ease complete this section �check box if this section does not apply How were you injured? What part(s}of your body were injured? Have you sought medzcal 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 resuIt of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone �Checfc here if you are attaching more pages to this ctaim form. Number of additional pages � . By signing this form,you are stating tltat�Zl informc�tion you )aave provided is trice and correct to tlze best of your krzowledge. Unsigned forms will not be processed. Submitting a false claim can result in prasecutio�t. Date form was completed _ 7�-o��- �y Print ihe Name of the Person who Completed this Form: VY -S�e.� �.J�� _— Si�natnre of Person Mal:ing th.e Claim: � � Revised tet�ruary 201 1 � � �' �e� I f� c; �.,�, o�- �a��� Aa w I �-s ; ('eSpansi�,le T'�� �� /�tirYi�f�t. �o A't� t%�*Z dGCw�s �. � -t►�� pb�- hor� ��� �- � -�� �� �� �.��1�, y O� �"� r�Dad,y � ...�w�11/� 7U ��t�+� I�l' � G�.� M�t� �o PdT h o�2.s �l S „t Cc�� ��!`'�l��e sa� . �jG.S� a lo �� � �� �- ;o �t � �'t 7� f"� G�oeS aGo �o� �cc�S li✓o /T �t 0� ��t�afL° �"v ✓j1� c�L� � _ ; l��icfz. �-�`����9.e, a��, �' /,�o��ti� a n�� ��� �o ?' �'�� �d l,a ,..�. � �'e �r� � f� 'v�.�, c� �/ : S� � d,'�1�� ��,� � �� z�,ti;�s ���- � o�%`�. . .�J-, ?�he� r,^�s ofe 1���� �'�w� .�����s z 6�- . th� ���- �,o��. 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'�. ��� t���'3 I'd;,t i �i��a�,-;�._�:� :��r�. _ L � '�F'I:� H�:;, . _ .. i ._� ` _ ., _ ��` C r_:..,- � � �_.._y:�,7 �r^ t Ttr°r-. •T i. t1E,G��, ��a�{��; _ i� �i ii �ti:�1 i rs� IG��f �_.`_�"CIME 1=�`i-:�:, k�, li�,GLl;uc_u .ti��' . �'s�1 , k4.� ___ ,, �:.,. � ;���- � ,-,, - r-• i 4y.—. .: _.IC, .yfj, i �t �Fi; i'_ �� j' ut�oc� �-a�.:�� _ rrv� -4.` ��.. � _i�, ;�:.: � LAL4'� ,:.T (�.�JL:�+L,z: .��Ls r'o u� t e ..� cG�r�',ME�'JT: raFi-�GI���riti��£�.i: �'��--i�-_.����=+ ��a I:i t=�r� �'�il?C@ v0�; `!cl''-`� �}lii'`Cricl=�L'a {E'4V�''f' �'�lc�it tt�'tlt-' �:LT'e1' lClY' Vvi""3(_ta�i) y �tJt Wli�. ITIO�_tP� �:��C-' i`iC-'W �.lT"'G5 OT7 4ii: L ' + t Y, t ���'L'ir� �. . 'Y J�_�f�� 'd�t'�'_{�.e.:...1�' ! L i �-°_''��+ .r.'�l �i.�'� �.'tii� �ICI:�i..{i.l.�gv °v,�I�T�TAL; 1��� �.?' '"�1 X. �__�1�'� l'�i�fiL. c�k'. �� ;.t-I�Yi���td�-:�'� t��: �frVL+. �ta �L�kh XY,XXXXXXXXXX �J1� Vi::,A: 1J�:aJ`? 7 LiV1Jt�Eu: �v�1�• �'= r'�1'�Tlclt.�_l�i'� tJri tii:. ��� 100% recyclable paper �--.� �.- , _ �,'� -` -�" .::"==^.,,��?,�`�`' _: _`�__�"—,t`=�✓���'� LIMITED WARRANTIES /���:���. .iJ�p��r�iw'IPJr�l�C���r..iw�dii'��r�R�H� ���0�'P�!��!idPii��'R�4�J���.PC�iS������r���:e4��1�J���ri�.q'J�iO�OPi0�i0��y�Pi�i����'iii��Q�,`•,��i) �`�f:: 3'�Pe'r4�t�MVi'�i Vf��O�'hr.��'P�0"Vr���'�V�'Pk�a1'Pth'i� "��'�'+'�h� ���O�v�,, '�1"���A'�W��JY�V 'i'1�0�' r1i�`��it�'i�Yr iPi�V',��„ �tii9i ��'��9� .'�t�'r� .__�;�� �,u,r ,��+� H� ��i z��,N� �� !1 t � , � � �«__. D1SCOUnt T1PC and AIY1Ct'ICa's T1TC StOTCS '�-� � � ♦il 1'�� t s� �.s !!��� �, •'- ����,�,���� - y� ELIGIBILITY-These Limited WP rranties apply�all own ty of the tire using ` +;"� it in noncommercial service,exce t for the Milea e Warran which is limited 1�i�1 __-_ __. _:;` to the original purchaser. (+' .� FO R R E PAI R, R E FU N D O R R E PLAC E M E NT � ���') To MnxE n c�M -r�esea�You<«<ecs>a�a orig�a�sa�e5���o«e�o any � — ���. ,; Discount Tire or America's Tire Store.To locate a store you may call 1{88S)774- �;i�v;�� Fot a fee collected at the ticne of the original tite purchase or for a fee collected to s�bject .!,,,r� 6560,or visit the Discount Tire web site at www.discounttire.com.The vehicle �`= = other Ures to the tertns of this certificate, Discount Tire or America's Tire stores will ,:-.'� on which the tire was used must be available for inspection.You will be asked ' +'�" to com lete the customer ortion of the ad ustment claim form. �,,1;,r.� refund the purchase price and the sales tax,if any,on any tire covered in the event of a :♦,.�ti�� p p j ' failure due to workmanship and materials or a non-repairable road hazard for the sen�ice '- �� � of the odginal tread down to 3/32 inch remaie�ing,or 3 years from date of purchase � � WAR1tAN'I'Y COVERAGE ,�'i4}�'.�.. ��.��f11:� whichever occurs first.Upon refund or credit of sales tax,customer hereby acknowledges > _- �= New Tires-Workmanship and Materials-If our examination shows by actual signature or electronic signature capture such ccedit or refund.This additional =' ,n� that a assen er,SW,or li ht tmck tire covered b this warran has become ��,i::� �. NI P S S Y �Y ;;_::._ acknowledgement satisfies a technical requirement in the sales ta�c statutes and/or ::._-,+',h'' unserviceable due to a workmanship or ma[erials defect during the service /, �' regulations for many jurisdictions that a signed receipt must be obtained upon the refund == ,,,,. down to 3/32 of an inch,it wID be replaced on a pro rata tread wear basis. l'' ,�� or credit of sales ta�ces.At the election of the purchaser,we will sell a replacemen[t�re � ���� to the purchaser at the original price paid for the damaged tire,plus the required sales : , New Tires-Road Hazard(if applicable)-If our examination shows that ���`;�� �.�'y� a passenger,SUV,or(ight truck tire covered by this warranty has become �.,.,,;___ taac•In[he event the covered tire is discontinued or unavailable,a tire of similar value will _, unserviceable due to a normal road hazard(i.e.,non-repairable puncture,cut, �� � be substituted. �= '� snag,bruise,or impact break)during the service down to 3/32 of an inch,it ��':�� If in our opinion,the tire can be safely repaired,we will do so free of charge.The cost of � '��i� will be replaced on a pro-rata tread weaz basis. ��.:� this certificate is set forth on the receipt issued for the purchase of tire(s). �� r�� New Tires - Mileage Warranty (if applicable) - In addition to the ___ This certificate will be honored at any DiscountTire orAmerica's Tire stores.This certificate _:_,;� warranties above, every mileage warranted passenger, SW or light truck dces not cover damage caused by collision,vandalism,chain damage,mechanical defects ' ,,;; tire is warranted to the original purchaser for the specified number of miles �i' of tread wear and against normal road hazards for the same mileage (if � � _I of the vehicle or willfiil abuse.No other property damage or consequenrial damage of any ,�'� applicable).ff our examinaUon shows that the tire covered by this warranry "'^� _ kind is covered by this certificate. � ''+��� has wom down to its tread indicators before giving the specified number �. �� There will be additional charges to purchase a new certiHcate for a replacement tlre and _: % of miles of noucommercial seroice ou the passenger,SW or light truck on � = which it was installed,it will be replaced on a pro-rata mileage basis. �,,:�� to bala�ce a replacement tire. �� 'i�� ` `� ATV/Trailer Tires - If our examination shows that a trailer or ATV tire �. � By redeeming[his certificate,the cusromer relinquishes the right to any manufacturer s _-♦-.'� covered by this warranry has become unserviceable,other than by a road �� :�° wartanry that may apply,and Discount Tire or America's Tire may claim for its own benefit , p;'i} hazazd,during the three year period following its date of purchase,it will >' —� any such manufacmrer's wamanty. .:��,}�, be replaced based on a chazge of 33%per year or part thereof of the original � �j, �� ...;;��},i� purchase price. �:c _ � • � • • • � � ' ������.`f, ♦_ + ;��i� CALCULAI'ION OF REPI.ACEMENT CHARGES - Tires are replaced �"'"'` -._°_::;�� under these limited wuranties with a comparably priced new tire at a pro-rata `�''= _-- if�' cost to the wstomec Tread wear is ro-rated on the basis that the tire is wom �..�_ �� D�scouNt �> p � ��+• _ � � � out when the tread is wom down to 3/32 of an inch remaining tread groove � . � ' �� depth or to the tread wear indicators on tires containing them.Tire replacement ��;�;�,.y!'�`� �.;?3�� cost is determined by multlplying the original cost of the tire by the percentage � - � : of tread used.Por example,if the original tread was ll/32 of an inch,and the � ��';�;��� T 1 R E �� r�� tire has 5/32 of an inch of tread remaining at the time of replacemeut, the -__:__ replacement cost will be 75%of the original cost((11/32-5/32)/<ll/3z3/32) /' � � I == ,� x 100).The replacement cost for mileage warrauted tires is prorated at a set � .��+ i4`� �;� char e er 1,000 miles driven.F.E.T.and state ta�ees are added to the r lacement �` 2. - :z S P eP '= �i�� 1�1i ��� 1 �y �1 �i� �ui� �u�� ��t���£�i�FM ���r- < wst.Additional ch es for mountin and balancin 1 �11� '7�r���i+r���A��/�����'�������i�������������r������ �...`; ,'`�1,!y1'�.�',.+ll��l���A��1�11�,..aA�����1�MR :1���/�f,'R#,�1�1111�i�+:�f�11�1�'�1 F�I�'�,�1�1�1`1�I�1�'1�'Rf��l�lt�1+�' �.i�� az$ g S aPP Y• ���i.��oA�:�.4P0�i0�r��rr���ti�0�p�4r �f,�01o{J N:Ta,�:y4.i.y���i J� v4 �i ��!.,.�.�G,,, �i4 ��i ���i �♦ +r� ` �j�""-=r� �%``_'�`+_, ������-� ,��`��yf� v"�V _- �, =__�� ITEMS NOT COVERED-These warranties do not cover: � �� `�� = The cost of any tire includes any wheel weights used in the balancing of the tire. • Use in commercial service such as commercial truck racing,street sweepers,off-the-highway tazci,limousine,or similaz service(however commercial service does not include use by the owner as transportation in , his/her regular trade or business); � T I PS TO I M P R OV E T I R E ' namage,destruction,or faiture due to accident,fire,or vandalism; • Inegular or premature tread wear caused by improper intlation, M I L EAG E A N D SA F ETY misalignment,imbalance of wheels,or wom out shock absotbers or brakes; , • Damage or failure due to non-tire causes such as being run flat,mechanical condition of the vehicle,cuts&om rims or chains,or any willful abuse; i �� �€JTATE TIRES � REPLACE • Problems reiated to the appearence ofthe tire afcer the first lo/ofwear. �I every 6,000 to 8,000 miles or when wom•out tires when built-in wear bars owxEn'S DUTIES-It is the owner's responsibiliry to: , necessary to equalize treadwear. appear across the tread surface. • see cnac cne cires are ope�acea ac proper�nftacion,pressure a❑a toaas; �REBALANCE � REMEMBER TO RETURN ' Pay applicable taxes and dealer services such as mounting and balancing; every other rotation to promote even to any Discount Tire/America's Tire store ' Retum the adjustabie tire and complete the wstomer portion of the adjustment claim form. tire wear and a smooth ride. for a tire inspection. DURAT'ION OF COVERAGE-These warranties expice three(3)yeats from �MAINTAIN AIR PRESSURE the date of purchase. as recommended by the vehicle or tire manufacturer.Cheek your air pressure at least � I CONDITIONS AND EXCLUSIONS - These umicea warrannes are cne � exclusive wananties of Discount Tire or America's Tire stores,are in lieu of the once eaeh month when tires are cool. wa�acies of cne man�a�curer,and set forth the exclusive remedies available to the tire user.In the event that the terms of an applicable manufac[urer's warranry �MAINTAIN ALIGNMENT ���� exceed the protection given under these wananties,Discount Tire or America's V Tire srores will honor those terms.Discount Tire or America's Tire may claim (FfOf1t&ReSf)f2P18Ce wOff1 SUSP0nSi0n P3rtS. _ � ` ' for its own benefit any such manufacmrer's warranry.These limited warranties � ��;E�KPs� do not provide compensation for any consequential, special, incidental or � PLEASE DO NOT USE A'�iR I i � contingent damages. Some States do not auow the exclusion or timitation of incidental or consequential damages,so the above limitation or exclusion may any"Fix-a-Flat"type products. ����� ���' not apply to you.Tires presented for a daim remain the property of Discount � � , Tire or America's Tire Stores.No representative or employee of Discount Tire or ��NSPECT America's Tire Stores may enlarge or alter these warranties. tires occasionally for excessive wear,tread coxsuniER RIGHTS - These limited warranties give you specitic legal or sidewail cuts,Of Othef ddfi1892. rights,and you may also have other rights which vary from State to State.