Soria, Jesse �
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NOTIC� OI' CLAIM I'�RM to the City of Saint Paul, Minneso aY 16 2p�4
Cf�Y ����K
Mi�rrresutn Stute Stut�ue 466.05 smtes t��at " ...everv persn��...wlin clni�ns dmiin��e.e froni a�iv municipnlitv...sl�ull ruiece tn E�e pre.sented t
�ni�erning bucfv uJ'Nre nninicrpaliry H�i�hin 180 dcn�s nfier�h��nlle,�ec!(��ss or inju�y is dise oi�ered u�iotic•e sta�i�rg d�e ti�ire,plare,u�uf
�•irrunistcr�rces tltereo/;crnd Ihe curruu�zt o/�compensatin�T or ollrer relie/'denianded.•'
Please complete this form in ils entirety by clearly typing or printin�your answer to each question. If'more space is
needed,attach additiona!sheets. Please note that you will not be contacted by telephone to clari('y answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being recluested. You will receive�►
written acknowledgement once your form is received. The process can take up to ten weeks or lonfier depending on the
nature oi'your claim. This form must be si�ned,and both pa�es completed. If somethin�does not apply,write`N/A'.
SEND COMPLETED rORM AND OZ'HER DOCUM�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �� SS� Middle Initial _�Last Name s°r� �`
Company or Business Name
Are You an Insurance Company? Yes Nc) If Yes, Claim Number?
Street Address � �� �✓r/'S� �o�,� � �,e.
City 5�� ��� � State (�"��• Zi� Code �S/D �
Daytime Phone (�� )8�$-��5�7 Cell Phone (7�� )�5C - ���y Evening Telephone (76� )2S°- 3°��
Date of Accident/Injury or Date Discovered ?'�� ��U� 7 Time �G�� a pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Ple�se indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. �" d ro�t-
o �'�� � ,�� -�- hol�. �oz��f �hra� ��� �� a� d �ne +�'�� d,��+,,�.qed 1?�
C�-� whe -e r�� bP,�`�- �
Ple�►se check the box(es) that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
.-v� ,
, ,•.•_. c.�._> _. n r� . ��:�,.� . ,.AU� ►.., •, ..1,,..,
l.� iVly vi;IliC1G WlIS U2111ia`b'CU U�' �! �>uut�uc Oi i:�riiC�lii�n� vi u,., ;.CCci u � y V�-i.1...e L✓::S .1::Tl�S�,.- � .: r.-.., -
❑ My vei�icle was wrongfully fpwed 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 you 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 clelay the h�uldling 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 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 �ictual bills
�►nd/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills, receipts
O Photographs are always welcome to documem and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
I?ailure to compicte and return buth pa�;es will result in dclay in the handling of your daim.
All Claims— please complete this section
Were there witnesses to the incident'? Yes No Unknown (circle)
Provic�e their names, addresses and telcphone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, wha[department or agcncy? Case#or report#
� Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility,
closest landmark, ete. Please be as detailed as possible. If necessa�y, attaeh a di��gram. (y-ra�� C�tY�� T"N�:u��o��
�Ct+�its /�v.NCf ol:•u� �rt��i �; v�- WL'•�T e✓Z+� b��c�Ar. f�:7 �►o�' 1'1tic� (',c)�'�' bc�c ��
��,��P�-+��, �
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ,',� , b�5� , ��
Vehicle Claims—please complete this sectior� ❑ check box if this section dc�es not applv
Your Vehicle: Year ���5 Make �,.,n�ic. c; Model (rG, frJ'
License Plate Number '12-7'�i I-1 State M�Color__ ���✓�,r
„
RegisCered Owner cj�s"5� �i � Sfl c'���
Driver of Vehicle ��55� (C'- Sr r���
Area Damageci `i h�e` r,�r�'S o n� -���r� P D-f'h o���S,
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injury Ciaims—please complete this section Cr�'clieck box if this seclion does not apply
f�ow were you injured'?
What p�u-t(s) of�your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment (circle)
When did you receive tre�atment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
Wnen tiicl yuu miss work�! (provide ti�tte(s):
Na�ne of your Employer.
Address Telephone
❑ Check here if you are attaching moi•e pages to this claim form. Number of additional pages
By sigrtijtg tltis form,you are stating that c�ll informatiort yore have provided is true and correct to tlie best
of your knowledge. Urasigfted forms will►tot be processed.
Sr�bmitti�ag a false clair�z can resatlt iri prosectetiott. Date form was completed �� ����c'��
Print the Name of the Person who Completed this Form: �z SSE ��!� Qo I�� �°r � �'�
Si�nature of'Person Making the Claim: ^
Revised Fcbruary 201 1
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LARRY REID ' S ARROV�T BUICK-GMC �
1111 EAST HIGHWAY 110 �
INVER GROVE HEIGHTS, MN 55077 �
651-552-2222 (v
WWW.ARROWINVERGROVE.COM
� � • • •
5/10/2014 16002 1111
• � • • • • • •
360 CASH
QUOTE-QUOTE
7 LIST PRICE
NO RETURNS. . . AFTER 10 DAYS, ON PARTS ORDERED SPECIAL,
ON ELECTRICAL ITEMS, WITHOUT THIS INVOICE, WITHOU'I' THANK YOU FOR YOUR BUSINESS ! !
ORIGINAL PACKAGING, 20� HANDLING CHARGE ON ALL RETURNS
• � � ' � ' � ' � • � •
3 ►9597379 WHEEL 416 . 11 416 . 11 1248 . 33
SUB TOTAL 1248 . 33
T� 88 . 94
TOTAL QUOTE-DO NCT PAY 1337 . 27
QUOTE - QUOTE - QUOTE - QUOTE
Any warranties on the products sold hereby are those made by the manufacturer. The Seller hereby
Th a nk YO U expressly disclaims all warranties, either expressed or implied, including any implied warranty of
merchantability or fitness for a particular purpose, and neither assumes nor authorizes any other
person to assume for it any liability in cor�nection with sale of said products.
Received By Page 1 CUSTOMER COPY
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MN 55077
(651 )451-2100 .,�-� .,
WWW•PePboys.com '
- 05/02/2014 1 :02:37 PM CST
Trans. : 057ti05
Store: 0871 �r ��
' Re9. : 105 „ ,,,.. =
� Cashier, 36i3S15 ri11:105 � � !
t3�l..s
Service Wnrk Order COMPLETE
II�IIIIIIIIIIIIIIIIII IIIIIIIIIII 142oeE.MEND07R7RUAD
087 , IIIII IIIIII F
110505760520140502 INVER GROVE HTS, � I C� S
i Falken Ziex ZE329 MN 55077 �p,��
� TIR2$3727?_3 119.99 T ��
1 @ 119.99 (651 )451-21U0 �
Order}#:: ?103623
� www.PePboys.com
� TIRE IN�iTALI_f,7I0N PACKAG 37.03 T 12:21 :2? PM CST
� 9084807 05/02/2014
1 @ 37.03 Store'• 0871
! TIRE MOUNTING Trans. : 153717 Ti11:101
0.00 N Re9. : 101
9125984 1 @ 0.00
TIRE HANDLING CHARG � Cashier: 356822
� 3.00 N SRLE
8585558 1 @ 3.00 i I IIIIIIIIIIIIIIIIIIIII
WHEEL BALANCE PpSSE 14,99 N IIIIII�IIIIIIIIIIIIIII
8582685 1 @ 14.99
, ROFli HR?RRD WRRRRNT �,,30 08711011537i720140502
7 396.00 T
91�;8G85 1@ 15.30 333 Mf�CNINED PRINTED 4 � �9.00
'; 3C'�a155G��NEP 1 1/q R 3 �y i J33377511 396.00
01ii5386 � @ 3 74 Sub-Total 28 z2
. Urder #: 2103623 i Tax qz4 z�
;i Total q24.22
�� Sub-Totai 157,02 i Master Card (S)
Tax Account: XXXX?!XXXXXX'(1447 �
9,91
7ota1 166.93 Auth: 03158B �A� q2q.22
Debit Card (S) 166.93 Total Tender 0.00
� Account: XXXXXXXXXXXX5535 Chanye Due
Trace #: 00680649
Ruth: f.A)
; Tota! Tender 166.93 ���n 7
! Chan9e Due Customer CnPy
0.00
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PeP Rewards Number: 990245926959 � . I
Service Work Order Number
IIIIIIII III I IIIIIII II� d�c �'��c.
2103623 fL�'�H�e.cL
CUStOM2r COPy
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1<i26 E,MENDOTA ROAD
INVER GROVE HTS, J'
MN 55077
(651 )451-?100
www.PePboys.c�7m :
05/09/2014 1 :39:49 PM CST
Trans. : 057'!30 Store: 0871
Res. : 105 Ti11:105
! Cashier, 36E3815 1
, � Service Work Order COMPLETE
II�III�I�I III III IIIIIIII IIfIIII IIIII IIII�II
i 087110505773C�0140509
1 30913500PEP 1 1/9 R,UBBER 14.96 T
HLTTV913 9 @ 3,74
Order #: ;?103921
TIRE INSTRLI_RTION ON ALL 10.00 N
8582959 1 @ 10.00
Order �; 1103921
TIRE INSTALI.ATION ON ALL 10.00 N
8582959 1 @ 10.00
Order #: ;?103921
TIRE INSTALI.ATION ON ALL 10,00 N
8582959 1 @ 10.00
! Order #: ;?103921
TIRE INSTALLATION ON ALL 10.00 N
8582959 1 @ 10.00
Order #: ?103921
; WHEEL BAIANCE PASSENGER 12,9g N
, � 8582630 1 @ 12.99
i Order #: ?103921
� IJHEEL BALRNCE PRSSENGER 12.99 N
8582630 1 @ 12.99
' Order #: 2103921
WHEEL BALANCE PASSENGER 12.99 N
$582630 1 @ 12.99
Order #; ?103921
WHEEL $ALAN(:E PASSENGER 12,99 N
8582630 1 @ 12.99
i Order #: 2103921
� Sub-Total 106.92
Tax � 07 '
Total 107,99
Cash 110.00
Total Tender� 110.00
Chan9e Due _2 p�
PeP Rewards Number: 990245926459 j�t G ts
REWARDS POIPJT BRLANCE EXCLUDING M��,�1��
TODAY'S PUR(:HASE IS: 157
Servi.ce Work Qrder Number �f` �t�'J
IIII�IIlllllll�illl r'�.'s
2103921
CustoMer COP�
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