Landmesser, Karina ,
RECEIVED
MAY 21 201k
NOTICE OF CLAIM FORM tb the City of Saint Paul, Mi����LERK
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipaliry 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 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 dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CIT HALL, SAINT PAUL, MN 55102
� � v c� �NI'�'�N l��✓IC�6".�1 S�Se�`
First Name O�l`� 1 Mid le Initi st Name
C�mrany or Busfness Name
Are You an Insurance Company? Ye /No If Yes,Claim Number?
Street Address �7 S !�e ���(��"�
\ s5� a a�
City C�'+C�et � State � l�V Zip Code
Daytime Phone(S'� �� Cell Phone((�5r) �`��- �b� IEvening Telephone( ) ��m�
Date of Accident/Injury or Date Discovered� � Time�_am pm
Please state, in detail,what occuned(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 andlor responsible for your damages.
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Please check the box(es)that most closely represent the reason for completing this form: esZa�k.5.avw�.� �•
My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
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 copies of all anplicable 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 aze encouraged to keep a
copy fo yourself before submitting your claim form.
roperty damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
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 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 comulete this section/'�
Were there witnesses to the incident? Y No Unkn wn ircle • /
Pr vide the'r n es,addres es and telephone numbers: r�57'�o a� (��
, �
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? Case#or repoR#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. lease be as detailed possible. If necessary,attach a diagram.
5+l l� �re��,�� �Oue s'�. /���,�
Please indicate the amount you are seeking in compensation or what you would like the City to to r solve this aim
to your satisfaction. 3d � a- � � �
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Vehicle Claims- lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year�'�Make � A �-A7Q Model 3
License Plate Number - State�Color
Registered Owner -
Driver of Vehicl r� e�
Area Damaged c� � '�' � �
City Vehicle: Year ake Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-please comulete this section check box if this section does not applv
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 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 s � �
Print the Name of the Person who Completed his Form: _�QY� � Q �Q� � �e �S �
Signature of Person Making the Claim: / -
Revised February 2011
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License# �,1�. .� � �� State � '; { �Y '��,���..�.�� �, � �� ������,�:
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Mileage: � .-,»: miles@: '�'� '����� Vehicle Contents
Storage: days@: - ,
Misa Charges F Payment Method
P.O.# Subtotal: � '� O Cash ❑Check �J Visa ❑ Mastercard
T�: • � Credif Card Number
Mem# '�
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Comments:
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receiyed By: 1%Code: "� � # Auth.# �7��'�� �'�;
EO,E Ae an"equal opportuniry employer"this compa�s pol,icy,as v�e��zs.Federal and'Shte Law prohibits discrlminatlon imse�qplo�lne�t�d oo race,coWr,rel�pbn sex,naliona�onpin physical handicap,or age wdh respecE to indnrfduai5'`v�lw ar�at least 18 years of age
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J =M COOPERS T=RE $ AUTO STORES
' OWNED AND OPERATED BY A PROUD GOODYEAR INDEPENDENT DEALER �����$������
1835 DIFFLEY ROAD rorrwo�rK
EAGAN, MN 55122
(651)454-3250 GOOD�YEAR
FEDERAL TAX ID# 416282673 �DIINLOP
NONE@NONE.COM
=NVO =C E 05/05/14 05/05/14 KELLYI�TIRES
E - Z'1 65 Z7 07 : 10 AM 06:46 PM
TERR: 7384
PAGE: O1 NONSIG: 171694
BILL TO: KARINA LANDMESSER
4427 SLEEPY HOLLOW
EAGAN, I"II�I 5 512 2
PHONE 1 . . . . . . . (952) 686-4782 EXT. VEH YEAR/MAKE. 07 MAZDA
PHONE 2 . . . . . . . VEHICLE MODEL. MAZDA3s
DATE REQUESTED 05/05/14 VEHICLE COLOR. MAROON
TIME REQUESTED LICENSE/STATE. VXJ641 / MN
RETURN PARTS. . NO ODOMETR IN/OUT 085806 / 85806
SALESMI�i�T. . . . . . OC4 / 003 VEHICLE INFO. . 2 . 0
VEHICLE ID #. . JM1BK32F771656111 PRIOR INVOICE. 190064
ACCOUNT # COB TC CUST# TYPE/STATE AUTHORIZATION CREDIT CARD N0.
738400051 V O1 05655 0 MN 846731 HDC 9254
SLSM TECH PRODUCT CODE BC QTY DESCRIPTION PARTS LBR/EXCISE LINE TOTAL
004 009 046-100 R 1 CK BOTH R. SIDE TIRE FLAT FROM POT HOLE 00 00 00
004 009 046-100 R 1 WANTS L.R. TIRE REPLACED TO MATCH OTHERS .00 00 00
Q04 009 093-003 R 4 R�SE? TPMS IN!"_��TOR iF EQUTDpFp .00 00 00
004 009 057-000 R 1 CHECK BELTS SQUEAL .00 00 00
004 009 077-751 R 1 KENDALL SYNTHETIC BLEND LUBE-OIL-FILTER 9.95 10.00 19.95
004 009 046-000 R 1 VEHICLE MAINTENANCE INSPECTION 00 .00 00
004 009 047-140 R 1 BATTERY CHECK 00 00 JO
004 009 093-002 R 1 RESET OIL LIF� INDICATOR IF EQUIPPED 00 00 �0
004 009 047-268 R 1 RIGHT SIDE MOTOR MOUNT(HYDRAULIC)-CQ 106.49 76.30 182.79
047-992-600-0
004 009 057-269 R 1 A/C STRETCH FIT SERPENTINE BELT-CQ 58.99 54.50 113.49
057 886-2CC 0 SERIAL#. . . K050264SF
004 009 057-269 R 1 SERPENTINE BELT-CQ 46.99 00 46.99
057-431-200-0 SERIAL#. . . K060514
004 347-000-010-0 R 4 P205/55R16 MATRIX TOUR RS 50K +'`.�(; 72.90 .00 291.60
347-238-500-0
G ON T=N U E� N E XT PA G E
HAVE A QUESTION OR PROBLEM�
Please tell our store manager.We value your opinion as much as your
business.Should yo�need additional assistance,call our
CUSTOMER ASSISTANCE LINE 1-800-321-2136
,
J =M GOOPERS T=RE $ AUTO STORES
OWNED AND OPERATED BY A PROUD GOODYEAR INDEPENDENT DEALER TIRE&SESi!/C'E
1835 DIFFLEY ROAD ��esxawrc
EAGAN, MN 55122
(651) 454-3250 GOOD�YEAR
FEDERAL TAX ID# 416282673 �DL'NLOP
NONE@NONE.COM
=NVO =CE 05/05/14 05/05/14 KELLYI�TIRES
E — 2'1 65 27 07 : 10 AM 06 :46 PM
TERR: 7384
PAGE: 02 NONSIG: 171694
SLSM TECH PRODUCT CODE BC QTY DESCRIPTION PARTS LBR/EXCISE LINE TOTAL
004 009 041-263 R 4 NEW VALVE STE�1 2.75 .00 11.00
004 009 044-263 R 4 WHEEL BALANCE - COMPUTER SPIN .00 12.50 50.00
004 016 092-701 R 1 ROAD HAZARD PROTECTION DECLINED .00 .00 .00
C04 C16 093-101 R 4 w`�STE TIRE CISPOSAL FEE .(10 2.50 1C.�0
004 009 047-100 R 1 NOTE:CHECK ENGINE LIGHT IS ON 00 00 00
004 009 047-100 R 1 NOTE:BATTERY TESTING WEAK 00 00 00
004 009 047-100 R 1 NOTE:RIGNT FRONT STRUT IS LEAKING 00 00 00
004 009 047-100 R 1 NOTE:POWER STEERING FLUID IS DIRTY .00 00 00
004 G09 068-100 R 1- 10� LABOR DISCOUNT .00 18.08 18.08-
*THANK YOU FOR YOUR BUSINESS. WE REALLY APPRECIATE IT! -JIM, JEREMY, COOP & DICK *
VISIT US ON THE WEB AT WWW.JIMCOOPERS.COM
PARTS TOTAL. . . . . . . . 525.02
LABOR TOTAL.. . . . . . . 182.?2
MISC SHOP SUPPLIES. 29.29
CHARGED AMOUNT 774.44 SUB TOTAL. . . . . . . . . . 737.03
X_______________________ TAXABLE AMOUNT 525.02 SALES TAX. . .. . . . . .. 37.41
cusTOMER auTHORizarloN FoR ToTa� =N V O =C E T O T A 1_ $7 7 4 _ 4 4
TREAD L/F. . . . . 10/32 TREAD R/F. . . .. 10/32 TREAD R/R. . . . . 10/32 TREAD L/R. . . . . 10/32
HAVE A QUESTION OR PROBLEM�
Please tell our store manager.We value your opinion as much as your
business.Should you need additional assistance,call our
CUSTOMER ASSISTANCE LINE 1-800-321-2136