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Wuorinen, Sara RECEIVED JUN 02 ���4 NOTICE OF CLAIM FORM to the City of Saint Pau1, lv��s�ERK Minnesota State Statute 466.05 states that"...every person...whn claims damages from any municipaliry...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 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 ��� Middle Initial� Last Name r�v�v` �� �/` , Company or Business Name Are You an Insurance Company? Yes No If Yes,Claim Number? Street Address �b�� ���� r� �h'�`' City O��'� P� State �N Zip Code 55���Q Daytime Phone(��_l�� W�2�Ce11 Phone( ) - Evening Telephone( ) - Date of Accidend Injury or Date Discovered ( �' Time < <'S 5 am/�m Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of S 'nt Paul or its employees are inOv�ved�/apn�qr res onsible for your d�ages. V�10►.5 V� 'O�MQ. cL h� 0. 1�� l o { \ O �rv+CW � � S � } S S c� P�sbSe check the box(es)that most closely represent the reason for completing this form: /1 0}- hou. F;t►e 1� MA�2-�'� My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ,��i4fy 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 applicable documents. For the claims types listed below,please be sure to indude 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 submitUng 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 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 �- � - , i .. . � �.�L'�� ` . _ . . . _ . � , .� ., . � . . . ._ . . . . __ . - . _ . . . . _ _ � ' � . . � ..i ' � . . ., . i . . .� .' , �� -, . �� - .�. , i . - - - . . . . , .' i � . .. , . _, ..! �� .'- �" , t. i ._. _ ' . � - � Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please comnlete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: 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 street address,cross street,intersection,name,,o�f par#_or Afacility, closest landmark,etc. Please be as detailed as possible. If nec ssary,attach a dia am. {Ul r�l1CJw 1�`� �`j' P�a��-w or c� t Please indicate the amou tyou are se kin in compensation or what you would like the City to do to resolve this claim to your satisfaction. �LOlO � *� Q��c� Yl YY1 0� T�'��,b pIM S - Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year 0 0 Make Model License Plate Number State 11J 1 Color Registered Owner �� Driver of Vehicle AX�OI, V�O�i Y�J��• Area Damaged��lL�� Pass�e�n cv� 'ri City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniurv Claims please complete this section �B-c,'1'i�ck box if this section does not anply 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 bere if you are attaching more pages to tbis claim form. Number of additional pages By signing this form,you are stating that all inforination 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 Print the Name of the Person who Compl d 's orm: a �n 0� , 5ignature of Person Making the Claim: Revised February 2011 r � � � r ' � ` � � . . . �� ,k ;- � , ,e , ,� : ', ,. • � �.'_ '�_ , �:� � � .. ,. ,'s.yA• `�'E .:J r - � " � p �� , �. � � � ..,.� � x,.,r�& g3-�5��_ .�._ Y� ��.='�. +�„" � � f. ., k�s ��j3� � , . �x. � $� •: ��` "�.�� � ,� ;� t.�, ,��_ , � .. a. . ,.� ,�, �i � f , � _ y �. , ���t �� , . � - � ' . ��.� � - �{ - I �:;�#�4� �- .� . . .`. . . �� �� • �' � � . '. 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I ' . . . t� A'.' � � � ♦'� +'A .r�}� 4, g, .5 p . .�3 �� � �r�.(�� .� kffi 4 1Yr �I���I�7(',I� .. ... �F t :�� �,.. _ � �y sf. s� � � . !I�f �{j .��^ Fd�� .� �'4 4 {r��Y ��v7 s �£" � t �� �i' � y � ' ` ;� ''t r � �� V ���ift��i�l; ''` � ��� '� � t � . �� `. � I+� ���I � , � � ,� � -_�� "' �. t �> r� �4� , Customer Invoice TIRES PLUS Service Advisor: 130402 COON RAPIDS 08 TYLER 05/07/2014 3510 NORTHDALE BLVD NW 763.421.1413 COON RAPIDS, MN. 55448-1618 2009 CHEVROLET MALIBU LS DUNLOP, MIKE 3.5L V6 FI GAS VIN N OHV 12856 MANKATO ST NE Lic#: 775TNU WI Vin#: 1G1ZH57659F182835 MINNEAROLIS, MN 55449-4936 In: 05/06/14 8:08AM Mileage: 113,786 715.218.6453 xcwd Out: 05/07/14 8:32PM Store#244206 RETAIL'SALE � Rev Hist Unit Extended Job Description /Article# ID QtY _ _ Price Price Total - - - -- - - - -- - - - -- - - -- - COURTESY CHECK 08 PRICE OUT WHEEL COURTESY CHECK 7046930 99NS 1 N/C N/C FIRESTONE TIRE PACKAGE 08 98.39 149456 AFFINITY TOURING BL P225/50R17 93T 70,000 149456 99TN 1 89.39 89.39 MILE LIMITED WARRANTY DOT# 2RJRDBF0414 WARRANTY FOR AFFINITY TOURING P215l55R17 93T BL ORIGINAL ARTICLE#135805 PRICE 108.74 COLLECTED 65% REMAINING TREAD DEPTH 6/32 SERIAL#W2PJA1C421�2 7040215 ROAD HAZARD WARRANTY 7040215 99TN 1 10.00 1�0.00 PRT-DISC MILITARY 7097155 99TN -1 1.00 -1.00 ORDER NOTES CUST SUPPLIED OWN WHEEL/// Technici�n(s): 99 ROBERT CARLSON , Payment History: Summary:' Visa 4606 106.47 254378 Parts 98.39 Visa 4606 -1.07 ' Labor 0.00 Shop Supplies 0.00 Total Tendered 105.40 Sub-Total 98:39 TaX(7.125%) 7.01 Total $105.40 I have received the above goods and/or services. If this is a credit card purchase, I agree to pay and comply with my cardholder agreement with the issuer. Customer Signature Initial here to indicate you have received � the Tire Warranty Maintenance and Safety Manual. All parts are new unless otherwise speciflied. TELL US ABOUT YOUR EXPERIENCE TODAY AND ENTER DRAWING FOR�5001N SERVICE! Call 1-800-754-9817 or go to www.TiresPlusSurvey.com; Enter code 244206-130402 Offer expires 10 days from date of invoice. Good at all participating locations. �,J4n:°,r�' �";�r�rsr�'��!�,C;3�"'1 Page 1 of 1 `�w.. 4w/ ;_ �R, , Invt 131122.403001 . � . . . . �,�. �,��:�'. !.�: 4v,3 :�;;` . : `���liCi � . x°'.° � �=»6�d��9il�1i�� ���a3��,��.. �+�'x ����f�"�"�`° �'-. � . _. _ w : �;, y ,� '���:� � . ..,. . ,.. ,�s .t-., �:. t;l �� ,; —�:t . 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'''�U� ,,.;��_�vi)5. ;-- -,j,__ .___ _ __.- --_..- ._.�---- --.._ ,... __ .�,.__.. � �. � :� . --'- c-t.-vrai �"i.uiiivt�ar�:�.cn c-iivi 'aiiS vi�84J0-, .,..�"� .,,� , ,_ ..,.. ;c, ..,.. ,i i.�� rr�id�ais ir TYa`' 9 N ��� ; '�i_�., � � XCl�l�i. � b :�CW L%,B�R _. --- � �'l;rtn �3_�OC�M �s'"ai _ _ ��� , _ _ _ - ----� -- - -i , � � � , ,�, � 'ici o t�0 , -� �� � - . _ _ __ ___ -- - _ - --}--- --- ---. —_! '� � � �� , _�, �.bior i �.GUO Miies(41 12 NiontYis I i 2,000 Mlles(4) �� , �� _ _ __ __ _ ___ __ _ _ ---__ _ . _ - _— � � �12 Nonfhs�12 Q00 h4i es�=�,� � I " � - � _ � , �s i4i I - _ _ . _ _ __, _ ____ __ ' ?n� ,_ - - - � -- �'"„_ . _ �?'. �es.. � , .,,rfi . ::,.,,. 3°�'..' ' ,:< , � ,. . . ;_:�: ..�- ;�d� C��@==f�a��. ��"s'�'�;VP�� �tJ�i�S ;'F€i-VEHICLE. ---_ _ _ _ .__ � ��; r:s an.:all aaa��_��a�labcr ;r� warrantie�i tor a perio�c-1,�.ve��i� i 21��icn�`tis � � � � � � .ai��cr� .�ts, ,'',r � ��. � � . . �� .. . � � � . .. . .. .. . . -, ,�.�.-�i - =. U .ri ',-�I �gc.,�r;- . 4�tY�er S��rvE4.� 4�Var:�nty Exeiaasirans.�"�,: . � � ,�-�'�= � -�;�nclud.� ti�,e , :�Its�r��d�,tor hnses. Cost ot refr,gerant and i h.�rc�ing c,`�, �.,� �. , , ,: �.� , , , , ��� � �'�: ,r„� � ,��,r� ;ors �'ost of addlhonal brake system components. inciuding �� . , ��-,� �,�nc 3r�ke S��oes. Disc Pads, Calipers a,��d�rn��,N!�eel' "� . . . . . . _ ,-_ -. - .,=��'t'St��?�4'�:^.�"4� . . -. . ?t`. �. r����g�' _.�E� �� .,sr,-�: - ' .--, . .� . . 4�. . . _ . , _ . . - ,. ._ _ ,R � .._ '� ,;�r 1 ..,_ , . .��:'� .. ..,� �, , �:,._ �.:- , ._. � . � � � . „< , . . . � � � � �'���c; .-._ o .. C E� ..c�. .. ... . � . �. '..: . .. . . - � ... . .... �-�ii,. 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