Connelly, Kelly 2014-Jun-11 02 49 PM Ally 972-537-3305 [�Cn��\��D 2/5
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�1 �� l CrK�S 125q��' �7�5�? JUN 11 2014
c�� 3 z�6K�7 CITY CLERK
NOTZCE OF CL.A,AVI FORM to the City o#Saint Paul,Minnesota
M�nnwofn Srnte Sraiute 466,05 atarar fh�t"...every porson,..who clalm.r damagerJYnm ar�y municlpia►lry...ahall eause to bs present�d ro ihe
govarni�p body nf Ihe munleJDallry wl�tn 180 doys t�Jhrr fh�ollaged loas or i�/�ry i�ditevvai�ed a noNce atae�rg Ihs rbns,p�ac�and
clmemnances rhercof and rJ�e a►nounr ojeompen,tarlon or other rellefdenranded"
Pleesc comploto thfs form in its aottroty by ctearly typing or printia6 yoar enswar to eseh questioo. It more epace is
nceded�uttach ndditlonal she�ts. Plcasc notc that rou wW not be contacted 6y telephoho to clqtit�anawers�eo provide as
mucb informatioa as necesssry to explain your clatm�and ths amount of cotnpeasadon'being requ�ted. You w�lil reee{ve a
writte�acknowledgornont oncc your torm is recefred. The proc�e can take up to ten weeka or lo�er depending on tho
nature of yonr daim, Thls form must be aiened,and both p�es complelcd. If sotnething docs not ppply,wtite'N/A'.
SEND COMPLETED FORM AND QT�R DOCYfi�NT$ TO: CY'Y"Y CLERK,
7,5 WEST�LLOGG BLVD,310 C�TY HALL,SAIN'�'PAYJY�,IVYN 55X02
Firsc Nam�o 1�L-� ,_._, Middle Ynitiel � I,asc Name L. n��
Companyo�Busittas Name �'�F�/'y��c�.��..
Are You an Insurance Company? Yas��If Yes,Claim Nu ber?
Sueet Address �11 L.�`z�. ��s� p�` -_�.',� l'..� ��...�� �t—..C�L.�
City ���y�J�=\\� State "'r}C 2ip Code �SJ6�
Duypme Phone� 7�,� 3DSoCe11 Phone(_� Evening Talephone(_,,,�
Date of Accidend injury or Dace Discovered ��) 'I�me acr►�pm
Pleasa state,in detail,whot occurred(happened),and why you are submitdng a claim.Plesse lndlcatc hy h w you
feel che City of Saint Paul or ics em loyees are involved aod/ r res nsible for yo r damages.�� �
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pr�•r` . M c.or. ►^'� � �h �`'� °�c tf� � �`'�.
euse check the box(es)that masc closely ropresent the reason for comple ng orm:
❑My vebicle was damaged in an accident []My vehicle was damaged during e�ow
�My�ehlcle was dAmaged by u pothola�or cond�tioa of the stceet O My vehicle was damaged by a plow
I7 My vehicle wa9 wtongfully towed and/or ticketed C]I was injured on City propeYty
❑Other type of propercy damuge—please specify
�Olher type of injury—plcase speclfy
Ia order to proeess your claizn you need ta include cooies of all snali�c. ble doeuments.
For the clsims types listed below,please be surc to inc]uda the documents Indicatod or it will delay thu handling of
your claim. Documents WII.L NOT be ruumed und become the property of ihe Clry. Yau are encouraged to keep a
copy fo�youresolf beforo submitting your claim Porm.
O Property damage claims to s vehicle:two est�ma�es for the repairs to your vehicle if th�damage excoeds
$500.00;or che actual bills andlor cecelpts Por the repairs
O Towing claims: leglblc coptes of apy ticket issued and a copy of the impound lot teceipt
O Other propeny damage cluims:two repair estimates if the damaEo exceeds$500.00;or the actual bills
and/or rccelpts for the repnirs;dewiled list of damaged items
O Injury claims:medical bills,rec�ipts
O Phoeographs are always welcome to dxument and suppon your claim but will not be recumed.
Page 1 oP 2—Please complete and return Doth�ages of Ciaim Form
2014-Jun-11 02:49 PM Ally 972-537-3305 3!5
FaSlure to complete anKl return b�th pages wfll result in dela�in the handling ol your claim.
A11 Clalms�ulease cpmtilata this sectlqA
Were thete witnesses to the 1nC�dent7 Yos I�jo, Unlmown (circle)
Provide their names,addresses and telephone numbsrs: l�/�
Were tho police or law onforetrnenc called? Yes l�To Unl�own (clrcle)
It yes,what departmenc or agency7 /U/Qt Casa#or repon#
Where did the nccident or Iqjury tskc plac4? Ptovide etreet addtess,crose etreet,intvrsection,n c of park or fecillty�
closes�i�ndmark,ecc. Please be as detailod as possible. If necessary,attach a d9agam. �1 I
Plcase indicate tho ount you ar�aecking'n mpcasadon or what you would like t6e Ci to do to resolve chls la�m
tn your sqtisfaccion, S� M o,f`
�
�
Ve�}iele Claims�oleas�eQmulete this sec�lon �check box if this section doee not aovlv
Your Vehicle: Yeaz Make Model
License P1ate Number State Color
Reglstered Owner
Driver of Vehiclo
Area Damaged
City Vehiele: Year Maka Model
License Plate Number Stele Color
Drivor of Vehlclo(City Bmployee's Name)
Area Damnged
Iniurv Claims „QLase comalete ihis secj�Qn ❑check box��'this�ti�n does not apply
How werc you ir�jured?
What part(s)of your body wcre i�f ured?
Cieve you sought medical lreutment? Yes No Planniag to Seek Treatment(cizele)
When did you receive treacmo�tT (provide datc(s))
Name of Medical Ptovider(s):
Address Telaphone
Did you miss work as a result of your injury? Yes No
When did you mis�work? (provido date(S))
Name of your Bmploy�r:
Addross Telephone
❑ Check here If you sra attaching more pages to this ciaim form. Number of eddtdonal pages
By signtng this fo►tin,you are staling that all tnforntaKon you iucve provided is true m�d correct to the best
of your knowledge. Unstgned forms w�A�ot be proeessed.
SubmttAtng a false clalm carc resuCt in proseculion. Date tor,n was completed�le��K.�_
P�iat the Name oe the rcrson wbo Completed thSs Form: � �� ,►/ �,�,�r�
Signature of Person Mekin�the G7aim: � /
Revlsod�e0niary 2011
2014-Jun-11 02:49 PM Ally 972-537-3305 4/5
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� � Wisconsin Deparhnent of Trat�sportation �
� = www.dot.w�w�an 9ov
!��/�/ „`��� T965 S/l003 DIV1810N OF MOTpR VEFIICI.R�a
1111111 Flle� 781221 RI36
Januery 30,2014 RfSEARCH�INFORMATION
PO BOX 8070
MqDISOfV WI 63708�8070
ALLY FINANCIAL M���
JACQUErTA WAIKER RHO1sTRAT10p N F E T�RUSr
10946 MCCORNICK RD
COCKEYSVILLE MD 21030
RE 2004 GMC ID#- 1�KES12S9�t81y8517
Endosed is the veh[de record informatlon you 2quastad.
The fee for Bw vah�cle record intonriatlon you requestad Is kss than I�e amount you pald You wdl rooenre a refund of
50.75 In epproximetely onQ month.
Imagea ar�retained for 5 years frvm the date�canned and ere available back Do Ol•90 2009.
The ea�Uest ttttlt��ecotd for the 2004 GMC is dated Q6-28 2004, (mages for thl�t�ile number hwe�Desn purged
Ple�se prov�de a deytime phone number for Queatlons regatdinp ybur appllcgtbn;L,,,,,,),_,_„
It you heve any ques�ons,call(8G8)21�36�1469.rde�►horne ars snsw�ered between a;30 AM and 4:30 PM. 'fhank you.
9UREAU OF VEHICL�SERVICES
2014-Jun-11 02:49 PM Ally 972-537-3305 5/5
� ���-I - �l Ul.k► 3�Sti� .
��gGONS�N _
�� Wiscansin Departmerrt af Transpo�tatlon �
www.c�o1 unimnlin gov
1.
D�n 61on Ot Motor Veh�cies
O�� 49D2 9hCb0ypen Ave.
Mad�son.W153707
Thie vehlcte record was croeted on 01-30-2014 pt 08:40:13 AM,The mformellon ls current es of thls date and qme,
Veh(cle Details
Ths vohiclo tQ a mod�l yoar 2004 OMC ENVOY XUV VIN:10KE812S&10178617.71�e most rece�t color on O�e Is RED.It
Is kept In the City of OAK CREEK In the oounty vf MIIWAUKEE.IMs00T shpwe lhe tn�ck currenUy has a VAl.fO 9t3tus.
Other vehlcle details.
Fuol Type:Ge�
Styla�5PORTUTILITY
Orosg Welght Retln�:B4OD1.10,000
Odvrneter Detaifs
The last odometer reading on flle is 8 MI racorded on 06-2b-2004,this we9 an aoNel readinp,
Title Details
The Tldollmage numbar Is 04147K�0086.The appl(cadon Was rocefvod on 05�26-2Q04 and Nros processed on 05-28-
2004.Thls dlle Is the currerK tlUe for thls vehlde Gt YYlsconetn.(Please note tfiat ft fa possible that the vehlcle was�fn
enolher ateta and that atete hes not yet reportod the VYiseensin tlfte as csnceNed.)
Customers
Nan�e Ro!• Ad
VENNEAAANN TIMOYIiY A Primsry Owner 4109 S 7ROY AV�SAINT FRANCI8,WI 63296
MIL F�
Lions
O�dlis
ALLY FINANCIAL AcMdqr:LISTEO
PO 80X:8123 LEst Date:Ofr26-2004
CQCK Y E MD 2103
Registratlon Detaits
The reglssttratlon is for reglat�allon lype AU7,Ilcense pleta rype AU'I',plete number�92CLE.The RogisG�tloaAmage
number is R0174T5460016.Rag�slraUon e�gible for renewel,tl►e RRN number is 9725+1994221.The appllcallon toc
rcplstratlon waa recetved on O6-2s•Z010 snd Is ourrenty effacWe/roM 06-01-2010 untlt 05-51-2011,The produc�hea en
�em����ot os�o�-zo�o.The regisdstlon stetus is VAUD.
cuatam.w
ame I 04►es�
VENNEMAIVN YIMOTHY A Pdmary Ownor �108W5 TRO�AVE SAINT FRANCI3,WI 53235
Inspecttcn Malrnenance Detail�
Vehicle ie subJed to IM 7�adng.
2014-Jun-11 02:49 PM Ally 972-537-3305 1/5
Facsimile Cover Sheet
To: Sandra Bodensteiner
Company: �� , Z.6 G��5..7`r
Phone: 1
Fax:
From: K. Connelly
Company: Ally Financial
Phone: 972-537-3050
Fax:
Date: 6/11/14
Pages including thie
cover page:
Comments:
;
�
�
The infornration contained!n!h!s facsJmile mosaage Is prfvtleged asd confidan�ia!1rtJ'or►na�Jon imended only
or�he use of�he/ndh�ldual ot entlty na�ned above. �'the reader of�hls messa,ge!s not rhe Intended recipien�,
you are hereby nol�ad that prry dissemrnalion,dislrlbuflon or copy/ng of rhls communJcA!!on is strictly
prahibited. jf you have recelved thls commun�cat�nn in error,pleose/mmedia�ely notrfy ur by telephonQ ct ih¢
o6ove nwnber.
Thank you....,..Ally Financial.
r�xcovn�puel