Brown, Darlene RE��IV��
�UN 04 2014
NOTICE OF CLAIM FORM tn the City of Saint Paul, Mi�,n}�t�LE��
�
:Lfir.nescjar Sxue Srcrrwe-166.1)5.rxrres rlrat "...crerl'pei�:sn�:...who rl4rims dtittgz��es frorn nr.p rreuraicirxttiry...shc111 cerusr ro be preser.rect rn rhe
�of�er�ritrg fiaf S=o/'if:e-rxar�iri fxelir}.yuirhfn 1 SO days a/ier�he nll�,�ed lass��r•irajury is rliscoi�ererf a r.otice srcrting rhe rirnr,��l�ace,etr.rt
circurnstar.re.r tHereof,eYract thr antoun.t o{rvrnpen.satin�t or othe�•relie�'c/rrttarrcfed."
I'lease cornplete this forrn u�its�tlrc4�hy cle��rl�t�ping or printing ycxir ans�er to e�ch questicm. If cnore space Is
ne�le�i,att�ch adclItlonal sheets. Pleaise note that yuu rr�ill not be cQntactcxl hy�tdephunc to clarlfy ans�vers,so pro��ide as
rnuch i��tc�rrn�ti��n as iiecessary tc>ex�tain y�cx�r claim,�ncl the amount ejf cc�rnpens�tian bein�requestecl. �'ou�r111 receive a
writt�r�a�hno���lc�clgemc�t once yc�ur forrn ts recetvecl. Tfie pmcess can take up to ten rreeks or longer depen�ling an the
nature of�•our clairn. This fonn rnust be signed,:�txl t�ath pagts cornpleted. If sanethin�ck�es not appl�,H rite sNlA'.
SEND CUNIPLETED :FURM �iND 4THER DUCLTMENTS TO: CITY CLERK,
1� `�'EST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, l�'IN SSlt)2
Fii�t Naf��e;c`��1�° I�liddle Initi�al �I.ast Nat7x �!'Z�(�
C`ornpany ar ButiirYe��Name
?.rc Yau iu� Cnsuct�nce C��t�E?�iny�'.' �es No Ii'Yeti, C'laim Nan�t�t:r?
S€tzct Acldres, � � l � ��°� –
Git}�
c..)� / Q. State/'/�v Ii��C;ocle J�/0�
�� �� �yy�
� �:vc;niti�Tele hone(�_k�(z[Z-
C)�r�'time Phone(�)�c��C'ell I'hone( ) - F�
I��te of r'1GCident/[nj��ry or Date I�iK:overed J�o�� �� Tirtie �rm/��m
Ple��se stat�,in clztail,wh4�t��euri•e�i (h�yp�pened)> and���h��y�o�i ���e aubtnitting a cl��in�. Pl�r�se indic ate«hy�r ho�yc�u
t� the City o'Sr�int Paul or its em io}ees��re in��cilved andlc�r r�• onsib1e fc�r yo�,�,dam.it�es.
��c�5 riv�it a n � � e� �'c ��
Yn ►�Cu> � o �-s�
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Please ci�cck tt3e l,c�xt'es)tl���[ mz�st e;l���l� represent the reason for com�let�ng this 1'orin:
��1M��ehiele��-rxs d�it����ed:in an aceiclent � Mv r�hiile���as dam��ed durinQ a t�v��
']�Iy ti�ehiele����a� clam���ed hy' �� pothole c�r c�nclition of the street ❑ M}- vehiele�� 7� da►Yi:���d by �plt�v�r
� M�� �°ehicle wa� ��Fron�fully'tc�w-eci andlor tick�ted � ]���as ir�jai•ed-on City prop�:�ltv
❑ C�thc:r tv{�e ot'pro�.��:►ty�cl���ria�e–plet�� specify_ —
❑ (7t:t7et:t}�`}}e c�f injury�–pleasc.spec'tFy–
In t,rder to process y�our elaim�rou neetl to inctucle capies of all ap�ticable document,s.
For the cl�ims types listecl belo«-, plea�e be�i�re.to include the docu�t�ent�iraelic;ated t�r it u°il[ del�►y the hantllTng c�f�
v��ur ci�iri�s_ C3i�c����ments�'4'ILL:NC3T b�. ret��rnect anci b�co�� the p►•�perty c�f th�Ci[y. Yt�u are enec�ur�ged tc�keep a
c.op}`for yc�tu�eJf beYc�rr��iit�:���it�i n�y=c�ur e�frr�m��r�n. �
0 Prope�t}` dank►��e elairn5 tc,t� ti��hicle:twc7 c,tirn��tes i�c7r the rep.iij-�t�, y�our vehiite if the ciama�*e exceecls
�;SOq.{){}; arthe���i�,�►t c�;ir�r�„�i��r�r4�r�r,t�<�� tn�,•tE,a��-:
O Tc�u�ing claii��s: legik�le�opi�s c?f an��tick�,i �,sued aiid {t co��y af thc irii��ound Ic?t recei�,t
Q ()ther�?roF�erty�darna�e cla'rm5: t���o re�air c�t'rrnrttes if the daEl�age excecds��OO.OU:c�r elie��cival hill5
tinc�lc�r i•c'ceipts fe7r thi r�;��airs;detailecl li�t at'd�ima��ed items
O Injurv�lairm: it��ciical t?ills, i�cei��ts
O Photc?�r.�phs<�re al��av�welcome to dcx:urt�ent r�«c1�uE�po�t y�ur clair»but u ill nc�t be returned.
I'a�e 1 c►f 2–Please cc�mp�ete and reh�rn bath pa�es of Claint Form
Pailure to complete and return both pages��rill result in dela}°in the handlfing af your claim.
All Clalms–please camplete this sectlon
1'Ve►z ther�t��itnc4k.s to th< <n�idcnt`' Ye, No Unkno�vn {circlei
�'rc»ride their names, acicl�c�4c;�tnd telc�hcsn i1�he;rs: /'�e
V4'ere the police�}r la���enforcement calted'? Yes Nc? Unkno«-n lcircle)
ff yes, what de��aRrnent or a�ener�'? Ca�e#or r�port#
Where d:i�th� saccic�ent�r injunr t�l:� pl.�e? Provide �rc�t a�icirc5s,cross �tr�:et, interseetion, namz ot par�or facilit��,
�lo,�,t I��ij �3�irk,etc. ,lerrs� �::�det�iled�zs fx�ssible, It'neze: .�ry,attach �z dias�r��rn. 7�? ��
`)� c� � � ��r" ,Y-,/1-�}� ��,r, rlc�z�l�-E-�-�e�--
�
�l'le�t:re indicale[I�e��tnoiGnt you xtre.�eeking in c�oiripe;n,.�t ion or w-hat y�3u w�c�tcld]ike the�City t�dU tc�r�.;�tzlve[his claii�i
tc�yc�ur satisfactic�n.
Vehicle Claims– lease com l�te this secttan ❑e heck hox it'this section does not a�}Iv
Your l�ehicl�: Ye�rr !sb( M:�k� l�. Mot�el U��l�
Licen�e Pl�te N�ainb�r��-P 5te�t� h1►� Co1o:r��"
Rc��r;t�;recl(:h��ner ''�Q►1� (5��•'1� rowr�
Driver i�t'Velficte , � n�
�
ACea I��itlkl���(� YDh'�-- . � �'��1ef w ;l i�'1
C'itv �'ehicle: Year Mr+ke �'�UC1et
I�ice►�� Pfat�:Num�?er State Ccalor
Dri��er of�ehicle(Gity Emplo��ee's N�irn�}
area Dan�aged
It�iur� Claitns please complete this section �check hox if this�zctia�n cic�e,t�o2 a� I
Hc�«r �-e:re}�ou inyti�recl`'
VVh�xt part(sl of your l�c?dy werc inju►•ed?
Have you 5ou�ht rr�eclical treatment? Yes No Planning to See_k Ti�eatrnent {ci��le)
�Vhen dic��rc�u r�ceive treat►nent? (provi��date(s))
Narne�f'1�'I�ciical F'rovicler(a): —
r�ddress Tele�hone _
Did ynu r-��iss«�csrl:�i4�r�sult ufi}rour injur��"? Yes Nc�
Vr'hen did vo�� i���r,:� ���43rk? I.pr��v�idc date{s))
N�anie ot yoiu-Employer:_ —
Address Te[e:phone —
�Cl�eck het�c if�rnu are attachin�more pa�es to this cl�im form. Numl�er of a�l�iti,onal ages 3 . ���
d 51 2 t�t� 1 �ss�
By signi�rg this f or��yo s ar�s�rr�i���at�i f�ni�tiant yorc I a erprov� e s trzte�hc�7�c rrect tn tl�e best
of yottr k�xox�ledge. LFi�sig►�e�l�ornts w�CX rtot be �ro�essed.
.Subrnittirrg c� ftcls� rlai�tt cart result ira ��rvsecr�tion. I)atc�farm���as c��mpleted �D ��1'
Print thi=NaiiiE�of the I'erson w�ho Cam �. t 'orm: ���`e,�'1`� C1`�'rOI�J�
Signature afPenou 1��1xkln};the Claim: , ��k��
Revi scd F�l�ru:�ry?O1!
' '� NTB�
TIRES•SERVICE•BRAKES•BATTERIES
MN NATL TIRE & BAT ## 984 * * E S T I M A T E * * Page 1
1671 UNIVERSITY AVE Order Number - 51021771-ET
ST PAUL MN 55104-3726 Date/Time In. . . . . . . . 05/22/14 09 : 01 :40
(651) 646-0035 Est .Time Completion. 05/22/14 09 : 00 : 00
OIL LEVEL: Checked Empl# �
Verified Empl#
Lug Torque: Actual 2001 AUDI A6 QUATTRO
Checked Empl#
89 Verified Empl# Tag: 500ATE St : MN Mileage: 148365
Tire Infl F-34 R-34 TPMS Y N Engine: Vin: WAUZL64B91N163566
---------------------------------------------------------------------
Customer: 36314182 PO# : Ship To:
SCOTT,ARNOLD
200 WILKIN ST
APT 213
ST PAUL MN 55102
Opening Salesperson 12992951 Home# 651-235-0338 Work#
Ema�1 :
-------------------------------------------------------------------------
Item Number Item Description Qty Price Each Extended
------------------------------------------------------------------------
XPSTEER BOTH OUTER TIE RODS 2 72 . 15 144 . 30
New
STEERLAB /lOTH HR STEERING LABOR 8 10 .60 84 . 80
�^1A WHEEL ALIGNMENT 1 89 . 99 89 . 99
6 Months / 6000 Mile
IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK
TO OUR STORE MANAGER, SCOTT D. KEY
AT (651) 646-0035
PLE��SE READ CAREFULLY, CHECh ONE OF THE STATEIVIENTS
BELOW AND SIGN:
. r.�....,..�,.., .�,� ...��.... _ . __ �.__.�_.__ �� __ . ___ Tnt-al (''harrTC� '2� q no
�; �.. �.
�
-_ ,�n��;�a�-lM��r�r.s�j,�,� `,�'�•,�,��� �.
_ .._ , �
� ..,....�...�...,.,n,r.. .a._.,.�..�.. ...�.
New Tire Limited Warranty
"What is covered and for how long:
Every new tire purchased at a Tire Kingdom,Merchants Tire,NTB or Big O Tires store(collectively'TBC Retail')is warranted by the manufacturer against defects in workmanship or materials
down to 2.32nds of an inch remaining tread grove depth.Additional warranties may apply to some tires.TBC Retail will honor the manufacturer's warranty on any such tires,and any such tires
which fail under the terms of the manufacture's warranry will be repaired or replaced in accordance with the manufacturer's warranty program.You must comply with the conditions of the
manufacturer's warranty program to receive this warranty coverage.
*How credit is determined:
If a tire covered by this warranry becomes unserviceable due to a defect in workmanship or materials(tire separation,etcJ during the usable tread life of the tire(usable tread depth is original
tread depth minus 2'32nd of an inch),you will receive a credit for the amount of usable tread remaining on the unserviceable tire times the curcent selling price(example 60%usable remaining
tread times the current seliing price of$80 equals a credit of$48).This credit will be applied to the invoice of the replacement tire.
*What is not covered:
This warranty does not cover tires which become unserviceable due to:
l. Conditions resulting from road hazards such as cuts,snags itnpact breaks or punctures.
2. Conditions resul[ing from improper installation,wheel misalignment or tire/wheel assembly imbalance.
3. Conditions resulting from consumer damage such as improper tire and vehicle maintenance,misuse,abuse or accident.
4. Tire uniformiry complaint after the first 2'32nds inch of tread wear.
5. Use in any commercial application.
"See Other General Terms and Conditions below.
Limited Mileage Warranty
*What is covered and far how long:
If a mileage warranty is noted on the front of the documentation attached hereto,such tire whose remaining tread depth grove is reduced to 2!32nds of an inch or less prior to receiving the
specitied mileage,will be replaced with the same or an equivalent new tire at the then current retail price,including applicable taxes,less an allowance based on the actual mileage received at the
time presented to a TBC Retail store compared ro the specified mileage.Mileage warranry claims will only be honored within 6 years of the date of original tire purchase and before the tire
delivers the warranted mileage.The following tires are excluded from the limited mileage warranty:commercial use tires,tires worn from excessively aggressive driving conditions such as racing
and tires worn from improoer maintenance such as lack of rotation,imprnper?�r p*essnre,aL'gnment or mecha�ica!•.t�ear.
*Owner Obligations:
Proper tire care is necessary to obtain the maximum mileage and wear from a tire.It is your obligation ro see that your tire/wlieel assemblies are in balance and propedy aligned,that your tires
are operated at vehicle manufacturer s recommended cold inflation pressure and tha[your vehicle is well maintained.Your tires must be inspected by us a minimum of every 6,000 to 10,000
miles.Check air pressure in each of your tires including the spare,at least monthty when the tires are cool.TBC Retail will check alignment,treadwear,tire pressure and the mechanical condition
of the vehicle anytime at no charge at any TBC Retail loeation.
*What is not covered?
l. Defects in workmanship and;or materials(covered by separate new tire limited warranry).
2. Failurescaused by road hazards.
3. Tires used on special applications such as light trucks(unless specifically covered),vans,recreational vehicles or commercial vehicles including taxi,police,etc.
4. Tires with premature or irregular wear or damage due to improper inflation,misalignment of wheels,mechanical defects of vehicle or tires on vehicles where necessary vehicle
repair or maintenance has not been performed.
5. "fires damaged by fire,wrecks,obstructions on Ihe vehicle or willful and malicious damage.
6. Repairable puncmres or tires run tlat.
7. Sidewall damage from scufting curbs or oNier cosmetic damage.
8. Tires transferred from the vehicle on which they were originally installed.
9. Use in any commercial application.
*See Other General W'arranty Terms and Conditions below.
Road Hazard Warranty
*What is covered and for how long:
This warranty covers all tires for which this warranty has been purchased that has become unserviceable as a resul[of normal road hazards(i.e.cut,snag,bruise,impact breaks or ineparable
punctures).This limited warranry terminates when the covered unserviceable[ire is adjusted or when the tire is worn[o a level of 2/32nds of an inch,the minimum tread depth required for safe
vehicular operation.
"What is not covered:
Tires removed from service due to being overloaded,intentional abuse or tires used in other than normal passenger vehide service.Tires that can be safety fixed will be repaired FREE OF
CHARGE.Road service,towing costs and other incidental dama�es or costs are not covered.
*How is replacement price determined'?
Normal Road Ha7ards,Run Flats and Workmanshio/Material 9efcctx
In the event a tire covered under the warranry becomes unserviceable due to normal road hazard(example:cuts,snags,impact breaks or non-repairable punctures),(usable tread life is the original
tread depth minus 2i32nds of an inch),in the first 12mon[hs or 12,000 miles,whichever comes first,you will receive full credit of the original purchase price of the tire towards the cost of
replacement.After the FREE REPLACEMENT period of 12 months or 12,000 miles,whichever comes first,you will receive a credit for the amount of usable tread remaining on the damaged
tire based upon your original purchase price.(example:50%usable tread remaining times the original purchase price of$50 equais a credit of$25).This credit will be deducted from the cost of
the replacement tire.When the tire is worn down to 2 32nd of an inch or less,the tire is wom out and the warranty ends,regardless of the age of the tire.
"This warranty must be purchased for this coverage to apply.
*See Other General Terms and Conditions below.
O[her General Warranty Terms and Conditions
'"Who gets the warranty?
All warranties apply to the original purchaser and may not be assigned to a subsequent purchaser or owner of the motor vehicle on which the tire(s)covered by our warranties are installed.A tire
(s)mounted on any vehicle other�han the vehicle on which it was first mounted is also not covered by these warranties.
*Where to go Tor warranty replacement and/or service?
All TBC Retail warranties will be honored at all TBC Retail locations,including any Big O,Tire Kingdom,Merchant's or NTB s[ore nationwide.For warranty service,you must present your sales
invoice and service records,along with the unserviceable tire(s).TBC Retail s[ore locations can be obtained by calling I-800-NEW-TIRE,or in PA or N.1.1-888-T[RES NTB or in the white
pages or yellow pages under Tire Dealers Retail.In the event you are unable ro locate a i BC Retail srore or require further assistance,you may contact our CUSTOMER SERVICE OFFICE at
800-926-8473 anywhere in tlie Continental United Sta[es.
xConsumer Rights:
This warranry gives you specific legal rights and you may have other rights,which vary from state to state. Some states do not allow limitation on how long an implied warranry lasts,so the
warranty limitations may not apply to you.
"Conditians and Exclusions:
Nothing in this warranty is intended to be a misrepresentation that tire failure canno[occur.To the extent pennitted by law,liability for consequential damages is disclaimed.To the extent that a
manufacturer's warranty applies,such warranry shall be primary and the TBC Retail wattanty shall not apply to the extent of the manufacturer's warranty.
*Owners Obligations:
Proper tire care and vehicle maintenance are necessary to obtain maximum treadwear and service from a tire.It is your obligation to properly maintain your tires and the vehic(e,upon which they
are instalied.including:operatin�your tires at the vehicle manufacturer's recommended cold inflation pressures,insuring your tire and wheel assemblies are in balance,tires rotated on a re};ular
basis(every 6,000 miles is recommended),vehicle in proper wheel alignment and vehicle s[eering,suspension and driveline components are well maintained.TBC Retail will check and inspect
tire condition,wheel alignment and vehicle condition at any time without charge.
Pay Less Tires
698 University Ave , .,
��m� St. Paul, MN 55104
��� 651-298-8473 Invoi�e #25174
' Saturday,May 24, 2014
2:04:04 PM
DARLENE BROWEN
Ordered on
Saturday,May 24,2014
St. Paul MN 55104
Workorder#29952
MAKE�MOD FLEET NCi. PH�1E REP "' SM Q� .
2001 AUDI A6 4.2 QUATTRO AWD 4.2 651-224-3048 HMED SO AS Cash
LICENSE NO. MILES IN/OUT VM 70RQ�tE ENGINE SI E TRANS�A( i{)N C L PRD �
500ATE WAUZL64B91N163566 4.2L V8 PFI DOHC 32 AUTOMATIC
CATALOG DESCRIPTtON QTY PARTS LABOR DISC FET TOTAL Code
SL FIX WHEEL LEFT FRONT 1 80.00 $80.00 AS
We/come, We appreciate your business.
PAID BY Parts $0.00 Taxable $0.00
Cash$80.00 Labor $80.00 Non-Taxable $80.00
Freight $0.00 Local Tax $0.00
Other $0.00
FET �o.00 TOTAL $80.00
Supplies $0.00
Parts and Lador wairdnties 1G{7%/o�SiO days a4A�7mdes,xl�tiMevercvmies Aisf.Tha wairanty/imiled 10 d5e Kvnf"on dus 1bm�ony�eh,iah must E�ie(um�edlo aoshop al cusrome/s arpiense,!o honor
wemanty.lherobyauU�onze 65e ispair ironY fi de do�abng wiNr dhe nc�xssaq'matenals You aiM yvurempby�es mayop�e2le rnh;p�lapury�ses o/lesd'ng,inspe�cd'nn ordekrery af my�sk An expess
MF�chanic7s l,�n is acknow�fedged an�h,r,�(o setxae dhe avnDUnt a/iepaiis U�ernlo.You w�'not de he�H�nsibk forhss adamagelo►vhia(�o�a2�s k/lm�hk�fe m cas'e olfiie,dheR,acni�ent orany ob5er
duse de}rond yourcnnboL Because ofdhe exlent otdre leamfown andinsp�n,d�e�h�may�otAsrloim as�llas b�k�e.No 2fu�s on insb/A�d Tires and w Nmee/s,S�dalO�fers adiscnnb'nu�d ilems
Allie(ums a2 sub,�ct l0 15%hand6ng chaige.Any depasils aie sub�ic�ct lo foileil ilcanr,�
Print Name Signature Date
Page 1 of 1
Pay Less Tires
698 University Ave , ,,
�� . St. Paul, MN 55104 ; ,
,��� 651-298-8473 Warkorder#Z9947 `
Printed: 1:44:05 PM 5/24/2014
DARLENE BROWEN
Ordered on
Saturday,May 24,2014
St. Paul MN 55104
MAKE&MODEL L�ET NO: PHt)N E.P ` = �
2001 AUDI A6 4.2 QUATTRO AWD 4.2 651-224-3048 HMED SO - Cash
LICENS��It3° M��S iNIQUT : 1f�N T�R � EN�', ° ,
500ATE WAUZL64691 N163566 4.2L V8 PFI DOHC 32 AUTOMATIC
CATALOG DESCRIPTiON QTY PARTS LABOR DISC: FET T4TAL Code
OP NEW OUTER TIE ROAD 2 18.00 $36.00 AS
OP INNER TIE ROAD 2 46.00 $92.00 AS
SL R&I OUTER TIE ROAD 2 75.00 $150.00 AS
SL R&I INNER TIE ROAD 2 85.00 $170.00 AS
We/come, We appreciate your business.
[""-�`�"""-� : Tofque Parts $128.00 Taxable $128.00
� Labor $320.00 Non-Taxable $320.00
�-. N . ' -- Freight $0.00 Local Tax $9.77
Other $0.00
FET $0.00 �Sfim�te $457.77
' Supplies $0.00
Pa�ts and Lador wamdn�s 1G47%hr SY!days or4Gq7miks,wh�ieY2ra�ras bisl.fia wananfyG'rnileio'!o d�e Knik on Iha/oim ony.�eh�aW,mustbe ieGime�dlo ou�sAop at cwslomie/s expiense,fo hoiror
wairanty.l he�ebyauthodze 1he ieFair Knnik fol�done ahng witlr lhe necgssarymalena/s You�d}rourem,rnby�es mayoperdte�h,�k frxpuipnses ofles�g,insp�n ordeN'�ryaf mydsAr.An expiess
M�chanic?s�ien is adrnowkCged on vehk�fe!o serx�2 Me anwunl ofiepairs d�eie/o.You w�/not be he�fd 2sponsibfe foibss ordamage to veh�ck ora�dic%s kf1 m vehti6s in case oflire,tlreB acddent aany olher
cause deyond yourcnntrol.Because o/dre extentofd5e leaNawn and insp�iio2 d�e�eh,�maYno1P�O�m as��eNasG��B.No B/un�°�insb�d r"es and°rWl�ek S,�Cia/ONeis ordisc»ntinued ilems
All�etums a2 sub/ect to f5%handAng cha�ge.Any dePosifs a2 sub/i�d fo foifedr/cance0ed.
Print Name Signaturg Date
Page 1 of 1