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Dorsey, Angela RECElV�D JUN 11 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Min��c����� Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipality within 180 davs afrer the aUeRed loss or injury is discovered a notice stating the time,place,and circumstances t ereof,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 dces 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 _����� Company or Business Name �Fp" Are You an Insurance Company? Yes� If Yes,Claim Number? Street Address ��� �����L�� ��� � ' City ���LG �l�}�� State �� Zip Code ��� � Daytime Phone( ) - Cell Phone(�`C�� ���� Evening Telephone � �'S�- ���� ��1.�� �2o i�- � P Date of Accident/Injury or Date Discovered Time am� Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how you feel the Cit of Saint Paul o its emp oyees are i volvgd and/or responsible for yo r damages. ►''���r � . I •� �� � � G-IZ � LC� D n � 1, �(:� � t � `� �' ��� ; � '1 �.Q- Please check the box(es)that most closely represent the reason for completing this form: ❑�Iy vehicle was damaged in an accident ❑ My vehicle was damaged during a tow L�My vehicle was damaged by a pothole or condition o�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 coqies of all annlicable 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 r�airs 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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease comulete this section Were there witnesses to the incident? Yes N� Unknown (circle) � ` Pr�vide their` a�es, addresses ar� tele t�one nu bers: ' . �)''�v�. � U � C��U.� �1- � � rl ; V� , �� Were the police or� aw enforcement called? Y�es � o � Unkn wn ��cle) ��� ��K� � 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, close nd ark,etc. P e se b s detailed a ossible. If n cessary, atta�h.a,d�am. (0 -�� �-u�� �u,��s� 1� �� .�,i.� Please indicate the am unt yg!�are eking in compe atio��wha�you ould like theG�t'to do to resolve,��is claim to yo atisfac y on. �c�L�%�� — Y W G' t'�C,Y �� �,1�Q,Y) {JO�I d�,.��. �t,l.V ,�.e'1 k Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year�_Make D[�T1,�C Model - `T License Plate Number ��D� State Color �'� � Registered Owner r��%� � M ' Driver of Vehicle Area Damaged F'!�t-�� p/�5�1.�=�- (L��.'� � "j1 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 anplv 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 � By signing this fornz,you are stating that all information you have provided is true and correct to the best i, of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed ����2� ��f Print the Name of the Person who Completed thi Form: � � `v`` �4��✓� Signature of Person Making the Claim: `"-� Revised February 2011 aaa A U T 0 P A R T 5 REFERENCE NUMBER DATE 2871 WEST 160th STREET ROSEMOUNT, MN 55068 176056 /7/2014 13:42 PHONE 651-423-2432 • FAX 651-423-2808 P.O.NUMBER CUSTOMER NUMBER TOLL FREE 800-238-6664 www.aaaparts.com Qi MES DORSEY H ASH -ROSEMOUNT �2 71 160th St West I N semount, MN SSQ68 P T T O O SAIESPERSON ORDER TYPE TAX ID/CODE SHtP VIA PAGE 1 - 1 CAP C UNTER SALE N 1 QUANTITY DESCRIPTION UNIT PRICE • EXT.PRICE 1 5 0-06625 1N-Wheel; Stk# SB1213;AS15A01 $190.00 $190.00 001538011; NEW,REPLTCA,ALY06584U86N,LIST 354.00 ; Source:2009 6 ; G6 07-08 17x7,alum,(5 spoke),single,bright chrome(opt PFE� _ , . �.�� ;.�. ;��� '«,��{:._�� ,.�. ,�� � � � � � � �;.�� 3 � ��<# , k��� �,��� .,. �� ,� ��,� � ���;�� ,�r' � ; ' � NOTES: Thank You for � PAYMENTTOTALS PAYMENT NOTES: TOTALS CHARGE FREIGHT CASH DISCOUNT CHECK TAXABLE $190.00 CREDIT CARD $203.54 NON TAX $O.00 DEBIT CARD TOTALTAX �I3.S4 RECEIVED BY INVOICE AMT. CLUB# 06312 9925 HUDSON ROAD WOODBURY, MN 55125-0000 US (651)702-7970 LIC#WMT06312 DATE NAME 8280 IVYWOOD AVE S PHONE# 485700 27H71 03-07-2014 DORSEY,JAMES COTTAGE GROVE,MN 55016 (651)458-1690 YEAR MAKE MODEL COLOR LICENSE ODOMETER MEMBER ARRIVAL T(ME SERVICE COMPLETED TIME 0 2014-03-07 07:19 AM Serv�i�e Description Service TtRE INSTALL PACKAGE Whitewall-N/A 0.00 -Valve Stem-Drv Front-DECLINED Not Applicable -Balance Accepted-Drv Front-DECLINED Not Applicable -New Tire-Drv Front-DECLINED Free form -DOT Number-Drv Front-M740K01 R5113 -Dispose Tire Accepted-Drv Front-COMPLETE LUG'f'ORQUE Drv Front 100 FT-LB ADJUSTED TIRE TREAD DEPTH ����ff�. � Drv Froat-k0132 o $� A N Z~ � � � c`e 88 8888 •� � W��i �� `-r � �° ��cQi� (V �i � �_�S �2 � � �' ;. � � �9a��� m� � � $ o�ao=�s{a� ;�x m��C� g� t+.{��{ 6i� � � O^i c E a m� �b E y!s��� � $ � �7 `t � � ,'L�`g �� � ��'� g� � � ZM lLN_I �OOf—� r� �`�m 4�m � � ., � ?! ��� • !RN'Tll� r�w i�.-n •n n Lf� � � . MCrc \�� �° �"? ��n`'��z�i �ia *' rn� �+ ���R m � Z� �� �� i�; ��., �_iin�srvr �r R *%�f � s d m e s � z� _ �.! CT I— H �L! C'?7� � � � n �` Oo �� � �'$��aw � ���T .r�7��r' n i; � ? �}� � 7 � � � d� � G� �� '� > � �� ^ � O �� a �Z� ��� � � 2 � .. r� � �n `0 � �tnn a� � .. � R�g � � o �,,, p �fL� °+ 'a �� � � � � �; � �� � �o� �� � ,,�� cn �� � � �- a z z�� � � .� � � � N —p�p W 8 ^� � Member Ctrmments Total(Excluding Tax&Govt. Fees) 0.00 Technician Comments PLEASE READ IMPORTANT INFORMATION BELO Decliaed New Tire:CRACKED RIM. AND ON REVERSE DISCLAIMER&ACKNOWLEDGMENT 1 authoriu the stated service completion and give permission to operate the vehicle. l.Sam's Club is not rosponsible for loss/dainage to the vehide or items left in it. 2.When perfonning tiro services or non-tire related xrvices such as bettery,wiper,or any otha services,Sam's Club does not perform any tire inspections other than those indicated on this Smice Orda.Unlesa indicated on the Service Order,Sam's Club associates do not inspect the spare tin.if any. 3.Me�gbers should follow vehicle aud tire owner's manuals guidance and frequently check tires for proper inflaHon pressure,tread depth(mors than 2/32"in aU grooves)and conditions like tirc age,cuts.punctures,cracking,bulges and uneven tread wear. QUALITY CONTROL TECH:TAYLOR 2623 Driving conditions and vehicle operation may affect the safery and perfonnance of my tires SALES ASSOCIATE:TAYLOR 2623 1 have read,understand and accept ali provisions of the disclaimer and acknowlodbnnent ebove and the warranry statement on the roverse covering parts and service on this vehicle. TIRE ADJ ASSOCIATE:DUAINE 2692 TIRE TECHNICIAN:YENG 2744 03-07-2014 MEMBER SIGNATURE DATE HAVE YOUR LUG NI1T� RFT(�R(�11F.T� AF'rFU TuF FrucT sn�aTT Fc � � CLUB# 06312 9925 HUDSON ROAD WOODBURY, MN 55125-0000 US (651)702-7970 LIC#WMT06312 DATE NAME 8280 IVYW OD A S PHONE# 485700 Z78H'rJ 03-07-2014 DORSEY,JAMES COTTAGE GROVE,MN 55016 (651)458-1690 YEAR MAKE MODEL COLOR 2007 PONTIAC G6 White(Pearl) LICENSE ODOMETER MEMBER ARRIVAL TIME SERV[CE COMPLETED TIME AEK0669 76114 2014-03-07 02:55 PM 2014-03-07 03:17 PM Service Description Service N/C FLAT REPAIR 0.00 -Tire Pressure-Pass Front-CHECKED,30 -Tire Pressure-Drv Front-CHECKED,30 -Tire Pressure-Drv Rear-CHECKED,30 -Tire Pressure-Pass Rear-CHECKED,30 -Flat Repair-Pass Front-COMPLETE -Valve Stem-Pass Front-COMPLETE -Balance Accepted-Pass Front-COMPLETE -SAMS Battery Check-DECLINED Customer Request LUG TORQUE Pass Front 100 FT-LB _______ TREAD DEPTH — - _ -- — Pass Front-11/32 Merchandise Description Quantity Unit Price Merchandise � Member Comments Total (Excluding Tax&Govt. Fees) 0.00 612-817-8397 Technician Comments PLEASE READ IMPORTANT INFORMATION BELO Reason for Flat:Pass Front,NEW RIM AND ON REVERSE DISCLAIMER&ACKNOWLEDGMENT 1 authorize the stated service completion and give pennission ro operate the vehicle. 1.Sam's Club is not resperosible for loss/damage to the vehicle or items left in it. 2.When perfortning tire services or non-tirc releted smices such as battery,wiper,or any other services,Sam's Club does not perform any tire inspections other than those indicated on this Service Order.Unless indicated on the Service Order.Sam's Club associates do not inspect the spare tire,if any. 3.Members should follow vehicle and tire ownu's manuals guidance and fraquently check tires for proper inflation pressure,tread deptM(more than 2132"in all�tooves)and conditions like tire age,cuts,puncturcs,cracking,bulges and uneven tread wear. BAT7ERY TECHNICIAN:RYAN 1924 Driving conditions and vehide operation may affec he safety and performance of my tires COMMON TECHNICIAN:RYAN 1924 I have rcad,understand and accept all provisions o he disclaimu and acknowledynent above and the w ement on the rcverse ering parts and service n this vehicle. QUALITY CONTROL TECH:RYAN 1924 SALES ASSOCIATE:DAVID 2420 TIRE TECHNICIAN:YEE 1913 03-07-2014 E ER SIGNATURE DATE HAVE YOUR LUG NUTS RETORQUE AFTER THE FIRST 50 MILES.