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Stanley, Eileen �EG��`���� ' JUL 0 3 �0?4 � NOTICE OF CLAIM FORM to the City of Saint Paul, Minn ,�snta_ C L���� IIY Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the governin�hody qf[he municipulity wi[hin 180 duy,c uJ'ter[he ulleged la.c,c or injury is cliscovered u notice.s�uling!he[ime,pluce,unrl circumstances thereof,and the amount of compensation ar ather relief demanded." Please complete tivs fortn in its entirety by clearly typing or printing your answer to each question. If more sp�ce is needed,attach additional sheets. Please note that you w�71 not be contacted by telephone to clarify answers,so provide as much information as necessary to e�lain 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 � l First Name � � ��►'1 Middle Initial �"� Last Name O�►'1 �e �'1 Company or Business Name Are You an Insurance Company? Ye /No If Yes,Claim Number? Street Address I 3 5� S�X+a.x.-� �2 W City �,DSe V► l � State l�'' N Zip Code 551 �3 Daytime Phone(��1Q �ld�Cell Phone(_,} - Evening Telephone(� Date of Accident/Injury or Date Discovered �D����I`� Time � ��5 am,� Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you �eel t�e C�t3�o�Sai�t�a�a c�-ats er��oyees are�r��o��ed a�d/t�respcx�s�b�e for yo�r damages. ���v i n� t�l a►�h ov� �Sacl�s�t� 5-t �-F-o P D-� o�r b aS S o Y, �.w�c��'r�e, t3 l uc� Z � l 1�+ �-'�,res �'�,,�a S c�c,�,�� � hc�cl -r� c� 'i"r�o I� ,�-1 �,}-� l. �� 1�a— 2 ,�.. 4. !� 4 0. � ✓� T r..o� I,,e�e,,,_ r�p c�,,,�r�G�. Please check the box(es)that most closely represent the reason for complering this form: ❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow `�I 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 ❑1 was injured on City property ❑ Other type of properly damage—please specify C] Other type of injury—please specify In order to process your claim-lou need to include copies of all annlicable_documents. For the claims rypes 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 cop3��ar�+c�'belf befc�e�b�a�xt��g 3�c�it�clai�fc�. •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 ir►jttry ciaims: medicai�iiis,receipts •Photographs are always welcome to document and support your claim but will not be retumed. 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-please comulete this section Were there wimesses to the incident? Yes No nknown {circle) PrQVide their n�n�es,a.ddre�s and telephone mm�ber�: Ca-,r( �o►r 3��-( l Z�O- 1 p 4.SS�ho��1') � r l.s(Z- 2 - c( W�=t��ss a� h�s ou a✓ tl..� ��t�e Were the police or law enforcement called? Yes No Unknown (circle) S+.P�if es,what departrnent or agency? Case#or report# Pelr�e. C�- ��9� s�eP�v� tucl�e�.l� -j- we w.e.re o�.c�. w�m�-r�c�-c�r'�'� 1��►y� Where did the accident or injury take place? Provide street address,cross street,mtersection,name of park or facility, Y�� closest landmark,etc. Please be as rletail�d as po�sible. If necessary,attach a siia ram. SaG145 0►n S-{" N o r th b o�n�j v�S�- 5 o urP 1� o� �m,� i rr. D�✓ p asS Please indicate the amount you are seekin in compensation ar what you would like the City to do to resolve this claim f to your satisfaction. �g��� � V'E?p �0.�� '�-�2 2 NC t�.l�'�veS t�1'1u.t W�-re (',� S�'YOy2_G( _ 3 i�ei�ieie Ciaims- lease com ete t�is seetian ❑chec�C bcnc if this seetion does not a l Your Vehicle: Year 2-0°3 Make"�'o v s-f-a- Model r License Plate Number 1 S 9 t3�4�k R State Color 8 l u� Registered Owner F-�LP e v� �1 �-�-a,v�lt�e,� Driver of Vehicle I�t 1 e e� S-t-c�.v� l�� Area Damaged � T,r �r ' City�7ehicie: Year M e Modei License Plate Number State Color Driver of Vehicle(City Employee's N e) Area Damaged iniurv Claims-nlease comAlete this section Ll check box if this section does not anvlv How were you in3ured? 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 flf 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 attaclung more pages to this claim form. Nwnber of additional pages 6 . By signing this form,you are stating t7cat au inforn�ation you have provided is true anrl correct to tiee best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed �P.123 � "I Print the Name of the Person who Compieted this Form: �l �e.�.Y� �►'� �G� Signature of Person Making the Claim: Revised February 2011 ` t_ ' VROOOM AUTO CARE 2600 RICE ST INVOICE ROSEVILLE, MN. 55113 10204� Phane-651-484-8555 Fax-651-484-2009 Org. Est. #251729 Called Walking Wait Due � INVOICE Print Date : 06i23/2014 STANLEY, EILEEN 2003 Toyota-Prius- 1.5L, in-Line4 (91CI) 1356 SEXTANT AV�W Lic#: 159-BHR-MN Odometer In : 134484 ROSEVILLE, MN 55113 Unit#: Odometer Out: 134484 Home 612-770-9028 EILE---Office 225-773-5667 TED Vin#: JT26K18U730079003 Cust ID : 11544 Hat#: Ref# : Part t?esc�tptlon /Number Qty S,ale Extended Labar Dese�iption Mou� F.�ctended 175/65R14 T TP TOUR DT BLK CHECK HIT BIG POTHOLE. 77119 2.00 84.46 168.92 MAY NEED 2 TIRES?AN�RIGHT FRONT RIM? V�tVE STEM * 2.00 2.00 4.00 RIGHT REAR INNER FENDER NEEDS SECURING. TIRE DISPOSAL BALANCE 2 TIRES 0.20 21.00 * 2.00 3.00 6.00 REPAIR INNER FENDER SKIRT 0.10 10.70 BODY CLIPS Hazardous Materials 1.50 * 2.00 2.00 4.00 Shop Supplies 2.06 2.06 v�tuaon Auro caKe � 26Fikf R10E S I REEi L1TTLf CpNpi�fl MN 5511's 651 484-&555 h:�chant IL; 3ybI0b24Fi �ei �n IG: 1316 Sale VISR ;�XXXXX�r:�XXn395I Entrr Methad; SaiRed � Ap�rud: Online Batth�: �����3 iq6�23{14 11�12.19 In��� ������05 AAPr Code: �96�1C � Org.Estimate ;231.36 Revisions $0.00 CurreM Estimate $231.e iotal; � 2,��,�6 Labor: 33.20 Parts: 184.98 CUStaiurr CUNr Sublet: $0.00 7NRNK YOU Sub: 218.18 Tax: 13.18 Total: 231.36 Bal Due: $D.O� [Payments-Visa-$231.36 STORE HOURS: SUN:CLOSED MON-THURS:7am-7pm FRI:7am-6pm SAT:8am-4pm I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/o�your employees permission to operate the car or truck herein described on street,highways or elsewhere for the purpase to testing andlor inspection. An express mechanic's lien is hereby acknowledged on above car or truck to secure the amount of repairs thereto.Warranty on new parts and labor is 12 months or 12,000 miles whichever comes first. Signature Date �E+� Written By BEITZ.SCOTT-Tedxucians:LINOSEY,JONATHON 0.5 Page 1 of 1 Copyright(c)20'14 Mdchell Repair IMorrttation Company,LLC invhrs 03.18.2011 JD � .� , �;� � ��.. F G K a r�:� ` ' . i��',+�i*,�': 6 z^ + ` �`' .� r; ����� ����� � � � �; � „ � � 9 � ��,,��� �, • r ' � �{ "� }�.�u �t t.,�'� � ,. � rp �} $�,j��' :i � � `�tl'.�[ . :!�' �S1'F;�.�.� tN�# S�{ tl+'� "'Yi t'� .. . ! � ' 1'�'. � �'"FC� .'tir �t�x��F R�"'�� '`��`� b��r' •. 1 na *t s" +�4;� �`r �'�"c t � ��t .;`,�t` r:_�,r ',� `'?i '����� � `4t+ �,� '� '{'w ,�,�s� ...t�1}.;p. �'� ..pY `��'+s�"�1;� . 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