Fitch, Patrick REC���I�� 1
� JUL 02 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes�,dt�Y CL�F�i�
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 municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
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 infor�nation 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`��� �°� Middle Initial� Last Name /?��j
Company or Business Name �/� �
Are You an Insurance Company? Ye /N If Yes,Claim Number?
Street Address ��� � c���-�-�n-S �--
City�_��.��-� State/�J Zip Code-�J/C�,-�
Daytime Phone�i,j�)��!��V Cell Phone��)��-��-3a Evening Telephone�_�- �lU�
Date of Accidentl Iniury or Date Discovered � ///� Time�am�
— - - - - -
P'ease state :n detail, what uccurred(happened), and wl^.y y..0 u°e s�hrruttm�a claim.Please indicate why or how you
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Please check the box(es)that most closely represent the�eason for completing this form:
0 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 /'�t �-�s:'
Other ry e oi ro ert darr;a-e-� iease� �i�' i�ra d ��L►-��l�-��' - /r� /.[)D r��_�/l�0.(�•G�i
�� P P P Y b � P�� �Y —�� ---�a
❑ Other type of injury-please specify
In order to process your claim vou 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 aze 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 '
� 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
I �
1
I
Failure to complete and return both pages will result in delay in the handling of your claim. !
i
All Claims—please complete this section I
Were there witnesses to the incident? Yes No Unknown (circle) ,
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes � 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 necessazy,attach a diagram."��?41-5 0��
�F'� or� `iMo���S �lva C�.+� 9�t�"inn On f'D °l�'{ Pl�Sk �.�1 in.��' -�r o� �,•>(�usl.¢�
c��n �k1�.e. �l� �k c'�� �'u-�"`E'�.
Please indicate the amn»nt you are ePPking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�_����e'_�'
Vehicle Claims—please complete this section I ❑ check box if this section does not apvlv
Your Vehicle: Year�9�t , Make �IrISvN���t- Model Jklo�,s5 S��o'��
License Plate Number r�JE�3�2 State Vhl� Color �o�,
Registered Owner Qc��hr'.� �ok� ��k�
Driver of Vehicle i�•- Sa T �nn s o�
Area Damaged R� in �ro o� ��^'�
City Vehicle: Year ake Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'urv Claims ^Ulease complete this section � a LJ check box iT this sec[ion does no�applv `
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 treatmen#�? (provide date(s))
Name of Medical Provider(s):
Address I 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 Teiephotie
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
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 prbcessed.
Submitting a false claim can result in prosecution. Date form was completed CD� �°l 1��
Print the Name of the Person who Completed this Form: �P+T����- �`�'�'t� ��T�
Signature of Person Making the Claim: .�.� ��
Revised February 2011
�
Patrick John Fitch
Labor Cost for work done to 1996 Oldsmobile Cutlass Supreme SL
Work done on May 17, 2014 then again on May 30th 2014
La bo r:
INSTALL RIGHT C/V AXLE $150.00
INSTALL LOWER BALLJOINT $200.00
_ _
( 'Labor was done twice
� Work done by my father Patrick Joseph Fitch 651-734-8624 �
�
� EAST SHORE AUTO REPAIR \ �
ESTIMATE#
302 STILLWATER RD.
WILLERNIE, MN. 55090 007867
Phone-651-200-4989
�
ESTIMATE FOR SERVICES Estimate Date : 05/21/2014
1996 Oldsmobile -Cutlass Supreme SL
FITCH, PAT JENNIFER Lic# : Odometer In: 134687
1217 BURNS AVE. Unit# :
Saint Paul, MN 55106 VIN # :
Office 651-229-3732 ----Cellular 651-246-0107
Cust Id: 63
Part Description/ Number Qty Sale Extended Labor Description Extended
REMAN C/V AXLE INSTALL R1GHT CN AXLE 150.00
299002 1.00 95.95 95.95
LOWER BALL JOINT INSTALL LOWER BALL JOINT 240.00
49902 1.00 59.95 59.95
Shop Supplies 6.24
Parts : $ 162.14 Labor: $ 390.00
Tax : $ 1 1.11 Total : $ 563.25
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees
permission to operate the vehicle described for testing and/or inspection. Express mechanic's lien is hereby acknowledged on above vehicle
to secure the amount of repairs thereto..NO WARRANTY ON USED PARTS.NO WARRANTY ON LABOR WITH USED PARTS.
WORK DONE AS IS.NOT RESPONSIBLE FOR LOSS OR DAMAGE TO CARS OR ARTICLES LEFT IN CARS IN CASE OF F[RE,
THEFT OR ANY OTHER CAUSE.BOND ENTERPRIZE IS NOT RESPONSIBLE FOR VEHICLES OUTSIDE OF SHOP. ALL
CUSTOMERS WILL FORFEIT VEHICLE AND TITLE AFTER 90 DAYS NO EXSEPTIONS.
SIGNATURE................................................................................................. Date......................................... Time.........................
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Page 1 of 1 estl 07/17/03
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