Smith, Katherine REC�IVE�
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes�� 11 2014
Minnesota State Statute 466.05 states that ' ...every person...who clatms damages from any municipality...shall cause to be resented to the
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the ti��l�ic�a��E�K
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 �Q'{`�I�iYI Yl� Middle Initial�Last Name S�YI I-�
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?_
StreetAddress ?��0 SQIYI�' �Q,{�P,1� S�"YQ,��vfrli�l- ��7
City SCI t Y?�4� ���I State NI N Zip Code �510
Daytime Phone(q52)�-I�#51 Cell Phone(1n12�t�( ,2-2�5� Evening Telephone(_) -
Date of Accident/Injury or Date Discovered �-I �2�) � ��`� Time �00 am 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.
�-ieacl�rl .ea�-on C�rrand A�$ Y�.�S=, pa`� IA�CO�� �Vt�. �a•�r U�(ZY�-���i'iY►_ ��h�1o�-th�-t
�
p,,�•¢. dl� dnh�j��,s ¢Tn�.au J,�-_
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
`�My 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 youu need to include copies of all applicable 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.
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
andlor 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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease complete this secNon
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: �
��I-
Were the police or law enforcement called? Yes N'� 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 of park or facility, �
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. o AV�. �
� ' ' �lSt-
OY¢.M�hOUS� t'i�YN'�rOY� +ire. i n�l-an�pOpprc�.i�p}Y10�RS V►AW-,bLCXL�FirW'�i f0�'a�V��oy►oJ-}i�,f��
Please mdicate the amount you are seeking in com ensation or what you would hke the City to do to resol e this claim
to your satisfaction. � �r
��f - 'i� s v�.
Vehicle Claims—please complete this section ❑ check box if this section does not anulv
Your Vehicle: Year�0 i 2 Make Nl E 2t',E nES Model G300
License Plate Number kA fE W i N State 1�_Color P,i,qGl�
Registered Owner i�t+t�P,ti-i ne. Sm rt-h
Driver of Vehicle t=a�1-herin Smitvi
Area Damaged Frnv►�- i�i p�►�►t -ti✓�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—nlease complete this section �' �check box if this section does not anvlv
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 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 cJ+ � � ��`'�
Print the Name of the Person who Completed this Form: .�(�'�1�iV1Y1���1-�'�/1
Signature of Person Making the Claim:
Revised February 2011
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•I M P O R T S-
*INVOICE* 4901 American Blvd. West
KATHERINE ELIZABETH SMITH eloomington, MN 55437
350 SAINT PETER ST UNIT 407
� SAINT PAUL, MN 55102-1502 PAGE 2 Phone: 952-837-6300
HOME: 612-965-2756 CONT: 612-965-2756
BUS: 612-963-5219 CELL: 651-600-0868 SERVICE ADVISOR: 147 Paul Ru
COLDR � YEAR ``' ``MAK�/M.flDEL VIN < L1C£NSE ! MILEAGE IN/OiJT < TAG
•BLACK 13 MERCEDES C300W4 WDDGF8ABXDA809801 17949 17950 T8658
' DEL..DRTE i PROD.'DATE tNARR.;EXP. PROMfSED PO N0. > > tiATE �? FAYMENT s INV. DATf
30NOV12 I
30NOV12 D WAIT 01MAY14 0 . 00 CASH 30APR14
R:o.OPENED REA�Y OPTIONS: SOLD-STK:M2930 ENG: 3 . 0_Liter TRN:AUTO
30APR14 30APR14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
� >' ASK !ABOUT FELDMANN Ii�IPORTS''
*CONDITIONING SERVICES*
�. COMPLETE CAR DETAILING
' , ' I ' CLEAR F�LM .
WINDOW TINTING
PAINTLE'SS DENT REPAIR
' FELDIIANN IIIPORTS
9901 AMERICAN BLVD IJESi
BLOOMINGfON. MN 55q3?
�� 952-837-6367 � �
Merchant ID: 078102215 I I
Term ID: 2510
� S a 1 e <� �. .-
, . ..
VISp
: XXXXXXXXXXXX8923 ..
Entrv Method: Swiped
Aaarud; 0�1ine Batchq; 0d8883 "
84�30�1q < ,:: , .i.:;
16:25;47 , _
Inv�c 98873164 pppr Code; 450138
� iotal: � # 4�1 0�
. Customer CoPy C��
fHANk YOU!
DISCLAIMER OF WARRANTIES `DESCRIPTION TOTALS
THE ONI�WARPANTIES APPLVING TO THIS oAR71S1 ARE 7HOSE WHICH MAV BE OFFERED BV THE MANUFACTURER.THE SELLING DEALER HEREBV 2 O / . O O
� EXPFESSLV DISCLAIMS ALL WARRANTIES,EITHER EXPRESS OR IMFLIED,INCIUDING ANV IMPLIED WARRANTIES OF MERCHANTABIUTV OF FITNESS FOR LABOR AMOUNT
� .A PARTICULAR PURPOSE,AND NEITHER ASSUMES NOH AUTHORIZES ANV OTHER PERSON TO ASSUME FOR IT ANV LIABILITV IN CONNECTION WITH THE PARTS AMOUNT
SALE OF TMIS PARTIS)P.ND/OR SERVICE.BUVER SHALL NOT BE ENTITLED TO RECOVER FROM THE SELLING DEALER ANV CONSEQUENTIAL DAMAGES, 2 11 .Z rj
DAMAGES TO PROPERTV,DAMAGES FOF7 LO55 OF USE,LOSS Of TIME,LOSS OF PROFIT,OR INCOME OA ANV OTMER INCIDENTAL DAMAGES.
GAS,OIL, LUBE O . O O
�Anv warranties on Ne proAucts sold hereby are those af the manufacturer.As between this retail seller a�C buyer,the product is to be sold'AS IS'and the
entire risk as to t�e quality and peAOrmance of the proEuct is wit�t�e buyer.The seiler ezOressly disclaims all warranties.either ezpress or implied,inclutling SUBLET AMOUNT Q . Q Q
� any implied warramy of inerchantabilitv or fitness for a particuiar purpose,and the selle�neither assumes nor authorizes a�y other person to assume for it any c�
. liability in connection.with the saie ot said D�oducts.Th�s disclaimer by this seller in no way affects the items of tne manufacturers wananty.The buyer MISC.CHARGES �] .4 p
�� acknowledges be�ng so informed D��or to sale.
' TOTAL CHARGES 4 2 5 . 7 3
• X LESS INSURANCE O . O O
CLAIMS FOR WORK PERFORMED SALES TAX 15 .3 7
LAST INVOICE Jt/DATE: ALL PARTS NEW ORIGINAL
SHOP SALES MUST BE MADE WITHIN 90 DAYS OR EQUIPMENT UNLESS
4,000 MILES WHICHEVER COMES OTHERWISE SPECIFIEO P�EASE PAY ','
FIRST FROM DATE OF WORK. THIS AMOUNT 41�� . 1 O
THAN K-YOU
CopY��U��Z000 AOP,Inc.SERViCE INVOICE TVGE 2-51]C CUSTOMER COPY
.
. _ � �,
n-
.CUSTOMER #: 14��58 873164 FE1.DI��1NN
•IMPORTS-
*INVOICE* 4901 American Blvd.West
KATHERINE ELIZABETH SMITH
3 5 0 SAINT PETER ST UNIT 4 0 7 Bloomington, MN 55437
SAINT PAUL, MN 5 510 2-15 0 2 PAGE 1 Phone: 952-837-6300
HOME: 612-965-2756 CONT: 612-965-2756
�BUS: 612-963-5219 CELL:651-600-0868 SERVICE ADVISOR: 147 Paul Ru
' CL)LOR `YEAR MAiCE/MflDEL '' Vllal ' LICENSE '' NtILEACsE 1N/;OIJT TAG'
' .BLACK 13 MERCEDES C300W4 WDDGF8ABXDA809801 17949 17950 T8658
D�L. DATE '<.'PROD, DATE 1NaRR. EXP. PROMISfD ' PO N0. ! RATE ' PAYN[ENT i INV:DATE
3ONOV12 I
. 30NOV12 D WAIT O1MAY14 0 . 00 CASH 30APR14
R'.O. OPENED ' READY ' OPTIONS: SOLD-STK:M2930 ENG: 3 . 0 Liter TRN:AUTO
30APR14 30APR14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
� A' CUST�MER`` STATES:BLEW OUT I�%FR�NT TTRE
00 CUST STATES
996 CPM 0 .''00 0 .(7� ' �
PARTS : 0 . 00 LABOR: 0 . 00 OT�ER: 0 . 00 TOTAL LINE A: 0 . 00 '
*******�**��a�*�**���***** �****,�*****�*�***********+
'B COMPLIMENTARY MULTI POINT INSPECTION I
> MPI COMPLIMF..,i'�1TARY MULTI POINT TNSPECTION ' �
996 CPM 0 . 00 0 . 00 i
PARTS: ` 0 .0fl LABOR:', '' C3 . Q0 OTHER: `` b.fl0 TOTAL LINE B: 0;00 I
****************************************************
C** PRICE ON ONE RIGHT FRONT,' TIRE CONT� PRfl �ONTACT 225`' 45 17 BULGE IN
• SIDE WALL AND LEAKING
MA003. Miscel.laneous Maintenance �TRe�ta.ir ;:;
996 CPM ;; 68 . 00 68 . 00
1 :!Q-8-'40-0517 SKU 0352864 CON`�'IL`I��AL',� ' I
CONTIPRO CONTA 21� .25 211 . 25 211 . 25
- PARTS : 211.2 5 LABOR: 6 8 . 0 0 OTI�E�R:�<....��" ' 0 . 0 0 TOTAL LINE C: ; < 2 7 9>'.2 5
_
' MOUNTED AND BALANCED 1 RIGHT FRONT TIRE
****�*,t�**��*,�*'vr**,r*****>**�w:****�***�r***�****�**�**�
D** PERFORM 4 WHEEL ALIGNMENT
CAUSE: TNSPECT T�RE5, �t75PEI���t�laT;:.f�:��>� ST��2��C ��i�4��'I'�.AI3VTSE ON '
CONDITION, PERFORM 4 WHEEL �.L�GNMENT PE� MERCED�S '
SPECI�'TCATIONS, > `k'OAD' T�ST
ALIGN PERFORM 4 WHEEL ALIGNMENT
7004 CPM 139:0� :' 139 :00
PARTS: 0 . 00 LABOR: 139 . 00 OTHER: 0 . 00 TOTAL LINE D: 139 . OD
PERFORMED 4 WHEEZ ALIGNMENT''
****************************************************
•EST: 302 . 10 30APR14 16 : 12 SA: 147
DISCLAIMER OF WARRANTIES DESCRtP710N TDTALS
7HE ONLV WARRANTIES APPLVING TO THIS PARTISI ARE THOSE WHICH MAV BE OFFERED BY THE MANUFACTUPER.THE SELLING DEALER HEREBV ���
-.�E%PRESSLV DISCLAIMS ALl WARRANTIES,EITHER EXPRESS OR IMPLIED,INCLUDING ANV IMPIIED WARRANTIES OP MERCHANTABILI7Y OF FITNESS POR LABOR AMOUNT
� A PARTICULAR PURPOSE,AND NEI7HER ASSUMES NOR AU7HORRES ANV OTHER PEPSON TO ASSUME fOP IT ANV LIABILITV IN CONNECTION WITH THE
$ALE Of THIS PARTISI AND/OR SERVICE.BUYER SHALL NOT BE ENTITLED TO RECOVER FROM THE$ELLING DEALER ANV CONSE�UENTIAL DAMAGES, PARTS AMOUNT
DAMAGES TO PROPERTV,DAMAGES FOR LOSS OF USE,LOSS OF TIME,IOSS OF PROFIT,OA INCOME OP ANV OTHER INCIDENTAL DAMAGES.
GAS,OIL, LUBE
' �Any warranties an the products sold hereby are thost of the manufacturer.As between t�is retail seller and buyer,the product is to be sold'AS IS'and t�e
.. 'entim risk as ro[he qualitv and pedo�mance of the Omduct is with the buyer.The seller expressly disclaims all warranties,either ezpress o�implied,inclutling SUBLET AMOUNT
any implied warra�ty of inerchantebitity or fitness for a Darticular puipose,and the seller neither assumes nor authorizea any other person to assume for it any
liability�in connection with the sale of Sa�A pmducts.This tlisclaimer DV[his selle���no way affects[he rtems of t�e manufacturer's warran[y.The buyer MISC.CHARGES
� acknowledges being so informeE prior m sale.
• TOTALCHARGES
X LESS INSURANCE
LAST INVOICE 11/DATE: CLAIMS FOR WORK PERFORMED ALL PARTS NEW ORIGINAL SALES TAX
SHOP SALES MUST BE MADE WITHIN 90 DAYS OR EQUIPMENT UNLESS
4,000 MILES WHICHEVER COMES OTHERWISE SPECIFIED P�EASE PAY
FIRST FROM DATE OF WORK. THIS AMOUNT
THANK-YOU �
CoDV�iq��2000�DF.Inc.SERVICE INVOICE TVFE I�S12C CUS TOMER COPY