Illa, Crystle REC�IVED
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne�iS�a05 2014
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to`be�i�s�hte�4d�1�K
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the umount 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, I
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 ;
First Name
L��si l� Middle Initial�Last Name +'��4� �
Company or Business Name .
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address 3QQ� Q h 1.�� ���Y1�
City /v�1N ���� State I�'`� Zip Code �5v�+��
Daytime Phone(��-)�1$1- S`71 Cell Phone( ) �� Evening Telephone( ) _ 1 I �`
Date of Accidend Injury or Date Discovered 3���l� Time � ��Q a /pm '
Please state,in detail,what occurred(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 and/or responsible for your damages. �
I
I t,�aS r�n d JYti» a�� , L,��- ah� l��a� 7ou.%a�ca S S� ��au./ ,
a b o i ' `f-a F D n tf a m ' (� /� �
'�Y�Q� t�R� CL ki D�i�' a-3 �'#' I O `# I- ^ — (,c.�Q C b..e �rK� ;
-t' �-F' p '�-h O I� L# f1 f°i-v��^'��� i
� t,�As I -�'h i k fi, a ud n �n C-ar o! o� o h b u�-' d1 �t Fi h 1� i
1 �O u�d Ir� t O cn(��Sa- , �
Please 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
�y vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow �I
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 coaies 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 are encouraged to keep a
copy for yourself before submitting your claim form.
}�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
�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—niease complete this section
Were there witnesses to the incident? Yes No nknown' (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#ar report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facili�Y,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. �,QQ� Q� G{'LQQ'
�'a G v am
Please indicate the amount you are seeking in com�ensatj'°n or what you would like the City to o to resolve this claim ,,/�
to your satisfaction. � f l� aC� , 1� 1-'1't ��Y�" � fi110 � �LP1G'�PY
�-�-p b� 'f�l�?� Sct'cn0 -(- �'YtP.� ✓i M, T i �� =- $,1`l 'I�+'m � 1�1 a�N �
Vehicle Claims—please complete this section �check box if this section does not annlv
Your Vehicle: Year OD Make L:'�C i,t.�� Model r L �
License Plate Number State�Colar (�u�kb n 13Y�Dh7� }�PCZ✓f
Registered Owner C►�y 5-�-(� -f- I�y a n .�(1 q
Driver of Vehicle (!r��S i-7fi �t�a►
Area Damaged l��-f� F-r,a�r�-t' -I-�rP ,
City Vehicle: Year Make Model li
License Plate Number State Color ,
Driver of Vehicle(City Employee's Name)
Area Damaged I
Iniurv Claims—please complete this section �icheck box if this section does not applv I,
How were you injured? '
i
What part(s)of your body were injured? i
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) i
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)) I
Name of your Employer: I
Address Telephone ;
�heck here if you are attaching more pages to this claim form. Number of additional pages I
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
Print the Name of the Person who Completed this Form: (��S�� ����
Signature of Person Making the Claim: l�t Q,�--
Revised February 2011
����;�0 Date: 03/26/14 Invoice#{: 10870022462
=���R MEMBER PURCHASE INVOICE Time In: 15:28:33
Membership#: 1 1 1 804983 1 77
MEMBER INFORMATION VEHICLE INFORMATION
RYAN ILLA 2008 Acura TL Base "
3009 FRANCIS LN Color: BRONZE License:
ELKO NEW MARKET, MN 55054-5427
Odometer:
(952)797-2705 Wheel Torque: 80
(952)797-2705 Air Pressure: Front: 33 Rear: 32
ITEM# DESCRIPTION Qty SLIP PRINT
585316 POTENZA RE970 AS PP 4
ULTRA HIGH PERFORMANCE
235/45R17 97W XL BW '
BAN 105-086
40,000 Mile Warranty # MEMBEC� #t i 18049831�:�
6850 Tire Installation 4 s71�E�Ffi�F� fJRU�R * D��1�,F�7f;,°�44�2
3F'RICE iJ'r'nD 4 1� i�t',y'9
7023 Disposal Fee 2 s 585316 235�45kt? XL 5°9,46 A
�FRTCE t]VRD 4 (? 1�4,00 �
Keep Old Tires , 2 t M�TiBt�LF�iVCE 56.00 A I
tf'�:ICE OVRD 2@ 1 .00 I
t TIRE DI7f'QSL Z.00 �'I
s210000�393903 CFNiTI�ES 7C.C4- '
� A 7,125i TAX 4�,7�1
x TDTAL 634, 70
sVF An�erican Exeress 634,70
t
x CHA�lGE ,�70
t CoUF'f1tJS Tt:�1DER[D ru.oo �
aTQTA! NUMBER OF ITEMS SOLD = 4
tCASHIER: Krle R kEu� 95
x 3i26tZ01 f 15:29 iCfil 95 UO?� 6�!
I I I I!I I I I I I I I I I I I I I I I I!I I I I I!!!!I I I I I I I I I I I I
9200108700224625
D.O.T.#: RB8P9731413 RB8P9731413 RB8P9731313 RB8P9731313
NOTES: �
X X
X X
*Inflation and Torque speci�cations are recommended by Manufacturer.
Best to Spare �
Static Dynamic KYLE
Blackwall Whitewall Sales Person
— — Page# 1
Costco Road Hazard Warrant
TO QUALIFY FOR THIS WARRANTY:
1. You must be the original purchaser of the tires.
2. You must have purchased the tires from Costco Wholesale.
;. You must presentthe original purchase receipt and tire to a Costco Wholesale Tire Center.
CONDITIONS OF THIS WARRANTY:
1. The Purchaser must rotate and balance their tires as outlined by the vehicle manufacturer.
2. The Purchaser must operate their tires at inflation pressures outiined by the vehicle manufacturer.
3. The Purchaser must keep all mechanical parts that effect tires in proper working condition.
4. The Purchaser will be required to sign a"Costco Wholesale Tire Adjustment Form".
WHAT IS COVERED:
1. "Road Hazard Failure" is defined as a tire that becomes unserviceable due to cuts,non-repairable punctures or
impact damage.Costco Wholesale will repair tires with tread-face injuries in accordance with established RMA
(Rubber Manufacturers Association)standards.
� Z. This warranty covers road hazard failures in Passenger,Performance and Light Truck tires purchased from Costco
Wholesale.
3. This warranty is valid for either sixty(60)months from the date of purchase or when the tire reaches 2/32
of an inch or less in remaining tread deptb,(whichever comes first).
4. This warranty provides credit based upon remaining usable tread at the time of failure due to road hazard.
. "Usable Tread" is de�ned as the ori inal tread depth of a.tire less 2/32 of an inch(tread wear indicators).
5 g
6. Gedit is determined by multiplying the useable remaining tread by the current price of the tire.
7. This Warranty is a promise under certain conditions to give credit on a pro-rated basis towards the purchase of a
Wholesale meet certain s ecifications or cannot
new tire.This warranty does not imply that t�res sold by Costco p
fail.This Warranty does not replace or modify any original tire manufacturers warranty on material and
workmanship.
WHAT IS NOT COVERED:
l. A tire that is damaged/failed due to vandalism.
2. A tire that is damaged/failed due to an accident.
3. A tire that is damaged/failed due to commercial use.
4. A tire that,is damaged!failed_due to rac?ng. _ _ ____.________ _ _ __
5. A tire that is damaged/failed due to Off-Road use.
6. A tire that is damaged/failed due to snow chains or studs.
7. A tire that is damaged/failed due to rapid or irregular wear.
� 8. A tire that is damaged/failed due to wear from worn mechanical components on the vehicle.
9. Tires transferred from the vehicle on which they were originally installed.
10. Loss of time,inconvenience, loss of use of vehicle or consequential damage.Some states do not allow the
exclusion or limitation of incidental or consequential damages,so the above limitations or exclusions may not
apply.
j _ __ ___ - -- --__
TIRE'CARE RECOMMENDATIONS:
1. Kave the nir pressure in your tires checkec!�i�a tire pr�fessional ns least once n`nonth.Serious inju�y may result
fi•om tire.failure due to under li7flation.
I 2. Always request that the inflation pressure in your tires be set to the tire or vehicle manzcfacturers specifications.
3. Do not overload yotrr vehicle.Serious injt�ry may rescrlt from overlonding yot�r vehicle.
4. Register yoz�r tires using the DOT(Department Of Transportation)cni°d provided at t{�e tin:e ofpt��•chase.
5. Read nnd follow all tire maintes�nnce requirements outlined in the Tire Mnnarfacture�s Warranty bookfet provided
nt the time ofpurehase.
6. Always insist on an RMA (Rubber Manufacturers Associntion)approved two-piece tire repair if reqtrired.
7. Fix-a-flnt prodrscts s/�ozrld not be trsed. These pro�lucts void some manz�facturer warranties. Costco tivill��ot
pei fo�vn tire��epairs nn tires where Fix-n-Flat has been aised.
IJ you are parrchasing less than four tires, mot+nt the new tires on the rear of t{ze vehicle.
9 It is recomnrended to have y>ozrr larg nuts re-tightened 25 miles arter your tires are serviced or replaced.
0. Reqzrest that your tii•e a��d rirn nssenrblies a��e hand torqued with a calibrated tor9ue w�-ench to the vehicle
manufacttu•ers specifications.
11. Have yoa�r tires inspected by a tire professional at/east once a vear.
Rev.6-OS
iM
aaa
A U T 0 P A R T 5 REFERENCE NUMBER DATE
2871 WEST 160th STREET
ROSEMOUNT, MN 55068 181814 /26/2014 14:57
PHONE 651-423-2432 • FAX 651-423-2808
P.O.NUMBER CUSTOMER NUMBER
TOLL FREE 800-238-6664
www.aaaparts.com
G34133220
�tYSTALE ILLA H ILL CALL SOUI'H
�2 418 Hwy 65 I
44. S1� QETHEL, MN 55011 P N
T T
O �
SALESPERSON ORDER TYPE TAX ID/CODE SHIP VIA PAGE
1 1 KAS C UN1'ER SALE N 1
QUANTITY DESCRIPTION UNIT PRICE EXT.PRICE
1 5 0-71762 1N-Wheel; Stk# 5130214;AU02F04 $133.00 �133.00
U01560368; NEW,REYLICA,ALY71762U201v,LIS1' 189.00 ; Source:2008
T ; TI.07-U8 17x8 (alloy), 10 spoke,Alcoa mfr; Q:2006803; W:523038
1 C re charge $25.00 $25.00
R 001560368; Source:2008 TL ; W:523038
\
�
NOTES:
Thank You for our urchase!
PAYMENTTOTALS PAYMENT NOTES: TOTALS
CHARGE FREIGHT
DISCOUNT
casH �133.00
TAXABLE
CHECK $167 48 $25.��
CREDIT CARD NON TAX
TOTAL TAX �y���
DEBIT CARD
RECEIVED BY INVOICE AMT. 167.4�3
TM
Return and Warranty
Information
AUTO PARTS
Return and Price Adjustment Polic_y
All returns and adjustments are subje�t to the following conditions:
Returns Price Ad_iustments
• ,�II Rctumt must bc madc u�ithin 30 days oT the date of • All reyuests for price adjustments must be made within 10
purchase. days of the original invoice datc.
• Thc original in����icc must accompany all rchims. • Price adjustments will not cxceed SO�Ir of the original
• Parts must be returncd in the same condition,complete,and purchase price.
undam�ged. • The part for w�hich a price adjushnent is being requested needs
• Refunds processed within 72 hours. ro be in returnable condition.
• All returns are subject to a 20°Io restockine fee. • AAA may require documentation or photos oC the damage as
• Refunds on cuts and other non-s[andard or custom prepped justification of any price adjustment.
parts are subjeet to a 30°I�labor charge. • All price adjustments are for in-store crediL Credit memos
• All cores must be drained of fluids and complete as sold in expire one year from the date of issuance.
ordcr to obtain credil.
• Deposits or pre-paid special order parts are non-refundabie.
• All Returns are for in-store credit.Credit memos expire one
year from the date of remrn.
Warranty Information
Small Parts/Electrical Parts/Mechanical Accessories
• A 6 month part replacement warranty applies unless otherwise noted on your invoice. All claims for warranty must be made within this time.Any claim
made after the expiration of the warcanty will not be considered.
• The original invoice must accompany any claim for warranty.
• The defectice part must be returned to AAA for replaeement.
• A Life-time part replacement warranty is available for an additional fee and will be noted as such on your invoice.
• The warranty term is based on the original pumhase date.
, Driveline and maior components
• A 6 month part replacement warranty applies unless otherwise noted on your invoice. All claims for warranty must be made within this time.Any claim
� made after the expiration of the warranry will not be considered.
' • The original invoice must accompany any claim for warranry.
� • Defective driveline components must be made available for inspection by AAA or a representative of AAA while still installed in the vehicle for the
purpose of analysis before warranty coverage will be considered.
• New Fluids,filters,seals,and gaskets must be used in the installation of the driveline component.All lubricants and Fluids used must be of the type
recommended by the manufacturec Receipts for installation items must accompany the claim for warranty.
• Parts and Labor warzanties are available for additional cost and will be indicated on your invoice.Labor claims will be paid based on the Chilton Labor
Guide at a rate of$50.00 per hour.Labor warranties are limited to the letiser of the purchase price of the component or$500.00.
• AAA reserves the right to provide warranry repair at a facility of its choice.
• Labor claims will only be paid if a parts and labor warranty is indicated on your invoice.
• The warranty tenn is based on the original purchase date.
Sheetmetal/Body Parts
• Unless otherwise noted on your in��oice all Sheetmetal and body�parts curry u life-time corrosion or manufacture defect replacement warranry.
I • The original invoice must accompany any claim for warranry.
� • The defective part must be retumed to AAA for replacement.
Our Warranty does not cover the following items;
� • The purchaser's loss of time,incom�enience,Loss of use of the vehicle,towing expense,installation expense,commercial loss,rental cars,or other
consequential damages.
• On driveline components fluids,gaskets,seals,tilters,intake manifolds,exhaust manifolds,clutches,water pumps,wiring,thermostats,sensors,hoses,
belts,frolt plugs,tipark plugs,and injecrors are not guaranteed.
• Cluims that msult from accidenL abutie,ncglect,alteration,improper maintenance,or improper installation.
• Claims that result from the failure of other cxisting components.
• Claims that result from oaenc�ating due to cooling system failure.
� • Parts installed in vehicles used for commercial,racing,or off-road purposes,or parts used for uny purpose other that the original application.
• All warranties ure for the original purchaser only.Warranties are not transferable.
AAA Auto Salvage is a Gold Sea]Certified Automotive Recycler.Gold Seal recyclers set the standard for quality,customer service,and
warranties.AAA adheres to the strict Gold Seal Code of Ethics. If you feel we have not lived up to our promises or you are not comple[ely
satistied with your purchase please contact Gold Seal Customer Service at(888)385-1005 or www.a-r-a.oro.
,��t��dio �O�D I'he AAA Mission Statement: AAA Auto Salvage is an automotive recycler that
� �����m�� provides quality parts in a timely manner with no surnrises on deliverv.The AAA
�`�` � famil utilizes our knowled e and commitment to help our customers be completelv
�'����� ����m � satisged with their buying experience. �
AUTOMOTIVE RKYCLERS ASSOCIATION
aaa
A U T 0 P A R T S REFERENCE NUMBER DATE
2871 WEST 160th STREET
ROSEMOUNT, MN 55068 192154 /�/2014 13:59
PHONE 651-423-2432 • FAX 651-423-2808
TOLL FREE 800-238-6664 P.O.NUMBER CUSTOMER NUMBER
www.aaaparts.com
63-#13322(�
� ZYS1��iLl: [LLA H ILL CnLL SOU'I'FI
L2 418 f-I�vy 65 I
�� S'I�BE"I,HEL, MN �5011 P N
T T
O �
SALESPERSON ORDER TYPE TAX ID/CODE SHIP VIA PAGE
i - � Kns c uN1��� s���� N �
�UANTITY DESCRIPTION UNIT PRICE EXT.PRICE
1 5 0-71762 1N-Core Return; Stk#SB0214;AU021+'04 (�25.00) ($25.00)
1 001560368; Source:2008 Tl. ; Origin�l Invoicc:ll81814
NOTES:
'I'hanlc You for� our urchase!
PAYMENTTOTALS PAYMENT NOTES: TOTALS
CHARGE FREIGHT
CASH DISCOUNT
�0.�0
CHECK TAXABLE
($ZS.00� NONTAX t�25.UO)
CREDIT CARD $O,QQ
DEBIT CARD TOTAL TAX
RECEIVED BY INVOICE AMT. �2' ��
TM
Return and Warranty
Information
AUTO PARTS
Return and Price Adiustment Policy
All returns and adjustments are subject to the following conditions:
Returns Price Ad_iustments
• All Returns must be made within 30 days of the date of • All reyuests for price adjustments must be made within]0
purchase. days of the original invoice date.
• The original im�oice must accompany all returns. • Price adjusunents will not exceed 50%of the original
• Parts must be returned in the same condition,complete,and purchase price.
undamaged. • The part for which a price adjustment is bein�requested needs
• Refunds processed within 72 hours. to be in returnable condition.
• All returns are subject to a 20%restocking fee. • AAA may require documentation or photos of the damage as
• Refunds on cuts and other non-standard or custom prepped justification of any price adjustment.
parts are subject to a 30%labor char€e. • All price adjustments are for in-store credit.Credit memos
• Al1 cores mast be drained of fluids and complete as sold in expire one year from Che date of issuance. �
order to obtain cre�it � �
• Deposits or pre-paid special order parts are non-refundable.
• All Returns are for in-store credit.Credit memos expire one
year from the date of return.
Warranty Information
Small Parts/Electrical Parts/Mechanical Accessories
• A 6 month part replacement warranty applies unless otherwise noted on your invoice. All daims for warranty must be made within this time.Any claim
made after the expiration of the warranty will not be considered.
• The original invoice must accompany any claim for warranty.
• The defective part must be returned to AAA for replacement.
• A Life-time part replacement warranry is available for an additio�al fee and will be noted as such on your invoice.
• The warranry term is based on the original purchase date.
Driveline and major components
• A 6 monCh part replacement warranry applies unless otherwise noted on your invoice. All claims for warranty must be made within this time.Any claim
made after the expiration of the warranty will not be considered.
• The original invoice must accompany any claim for warranty. ,
• Defective driveline components must be made available for inspection by AAA or a represeutative of AAA while still installed in the vehicle for the
purpose of analysis before warranty co��erage will be considered.
• New fluids,filters,seals,and gaskets must be used in the installation of the driveline component.All lubricants and filuids used must be of the type
recomme�ded by the manufacturec Receipts for installation items must accompany the claim for warra�ty.
• Parts and Labor warranties are available for additional cost and will be indicated on your invoice.Labor claims will be paid based on the Chilton Labor
Guide at a rate of$50.00 per houc Labor warranties are limited to the lesser of the purchase price of the component or$500.00.
• AAA reserves the right to provide warranty repair at a facility of its choice.
• Labor claims will o�ly be paid if a parts and labor wsrranty is indicated on your invoice.
• The warranty term is based on the original purchase date.
Sheetmetal/Body Parts
• Unless otherwise noted on your invoice all Sheetmetal_and body parts carry-a life-time corro�jon or manu�acture defect replacement warranty. '
• The original invoice must accompany any claim for wananty.
• The defective part must be returned to AAA for repiacement.
Our Warranty does not cover the following items;
• The purchaser's loss of time,inconvenience,Loss of use of the vehide.towing expense,install�tion expense,commercial loss,renta]cars,or other
consequential damages.
• On driveline components fluids,gaskets,seals,filters,intake manifolds,exhaust manifolds,clutches,water pumps,wiring,thermostats,sensors,hoses,
belts,frost plugs,spark plugs,and injectors are not guaranteed.
• Claims that result from accident,abuse,neglect,alterution,improper maintenance,or improper installation.
• Claims that result from the failure of other existin�components.
• Claims that result from overheating duc to cooling system failure.
• Parts installed in vehicles used for commercial,racin�,or off-road purposes,or parts used for any purpose other that the originai application.
• All warrantics are for the origiaal purchaser only.Warranties are not transferable.
AAA Auto Salvage is a Gold Seal Certified Automotive Recycler.Gold Seal recyclers set the standard for quality,customer service,a�d
warranties.AAA adheres to the strict Gold Seal Code of Ethics.If you feel we have not lived up to uur promises or you are not comple[ely
satisfied with your purchase please contact Gold Seal Customer Service at(888)385-1005 or www.a-r-a.or�.
,��t��,'�aro ���� The AAA Mission Statement:AAA Auto Salvage is an automotive recycler that
� � ���o provides quality parts in a timely manner with no surprises ort deliverv. The AAA
r
�� ` ,,! family utilizes our knowledge and commitment to help our customers be completelv
����� �Ea�� satis zed with their buying experience.
AUTOMOTIVE RECYCLERS ASSOCIATION
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