Rehak, Sarah RECEIV�D ����Lk � 1 �-'
Jl9L 11 2014
NOTICE OF CLAIM FORM to the Ci��qf��i���il, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipadity...shall cause to be presented to the
governing body of the municipuliry within 180 days ufter the alleged loss or injury is dis•covered a notice stuting the lime,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 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 prceess 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
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First Name_ ��t'i�`4��1 Middle Initial � Last Name K-��1�ti}C
Company or Business Name ��
Are You an Insurance Company? Yes/�Vg% If Yes,Claim Number?
Street Address ��Z. � l� �p ��I� b��(�I�nA'IQ� � .��`( �
City (.L-T�f i�('.�� �,�--�kC�'� SCate �'�(lv\:��� ►'J� Zip Code �����. i �
Daytime Phone( ) - Cell Phone( G��)�-�i�Evening Telephone( ) -
Date of Accident/Injury or Date Discovered ��?4 J L�'i_ I'_,L�V q Time ���C� �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. � �1)��� -tY���� ��
� "c C, ` l✓ %a Y?e' I .,; , - ;- ".
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� �S�t'� �i'1-c��-!�-�cl.)
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 you 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 WII.L 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
�-��lG�k �_IrJ
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease comnlete this section
Were there witnesses to the incident? es No Unknown (circle)
Provide their names,addresses and telephone numbers: �;��4�'C�1� Ct'3�1������ 1`1i � t�y�lf' �i,YY�t�
����1' .�'1�1� ��'l�v�f��er I Clicl Vl�r �Cil-�c� i-�'�v ��ntc�c } ►��,r�u_��1(;vl
Were the police or law enforcement called? Yes � Unknown (circle)
ff yes, what department or agency? Case#ar 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. k��0�1[1 bl��� ��S�i
��I �c.Yin �tYZ�� l���li,�-�'�� i�� bvi��l��r �"��er�cUn�a y�1�'S�bc���d, i�'�n ��I���c�i�i���cl
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
toyoursatisfaction. � �-��yi i�"�(G�r�.��'�1li�rL��Y-�'�r,���,,�:,c',r1t��'1�f �1'�i ��Yi� L.��M►f'y�.vt,t'1f t'�} 1b�L%�r "L�
t��r `-}�e u:�- ��(- ��� ���YV nv�..� ��5 ► �V�;�.`, v�,ru.Y�tr }�-+�i-� f h� IJr-c�✓,��,. � rtr��,
�%�:� +,��►"� �i.�►Z c.r`� t'rrt�-� , -�2� C�` tz�X .
Vehicle Claims—please comalete this section � ❑check box if this section dces not apulv
Your Vehicle: Year ZC�12 Make 1�Y�� Model I�1,1 S i C(� S�L I�Vv�
License Plate Number State i�1ti Color '�1 L��
Regi stered Owner S Y�V�t-I M��'V-�1 G 1c�}i F��
Driver of Vehicle �w-1�►'-�r 1 t�1�q'Y�--1(:. 1�-r M�'j<
Area Damaged +�w�S(,= `(- �►2C,C�,`� Y�'t�;� l�I�11rZ `�1►LC 5
Ciry Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniury Claims—please complete this section �eck box if this section dces not 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 treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss wark as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer: I
Address Telephone
I�t Check here if you are attaching more pages to this claim form. Number of additional pages�. I
�I(.t�,LE C j �C'�"1C.��jt'C� �iS `v�°�� .
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 C% r � C t��l.�
r �?
Print the Name of the Person who Completed his Form: ������. �� I��Chl�1�
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Signature of Person Making the Claim: '! ' �
Revised February 2011
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CUSTOMER NUMBER: 2007051
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S� REHAK MINNEAPOLIS
9216 INDIAN BLVD S
COTTAGE GROVE, MN 55016-2273 �25 Broadway Street NE-Minneapolis, MN 55413
(612) 627-5556
www.boyertrucks.com
, minneapolis.service@boyertrucks.com
HOME: 651-253-4939 CONT :651-253-4939 SERVICE ADVISOR: 706 Scott Rehak
YEAR MAKE/MflDEL C4)LC3R VIN LICENSE UNtI'f�iUM��fi
12 FORD Fusion SILVER 3FAHPOCG1CR247531 203JGD
_ __ _ _. _ _ _
MILEAGE TAG PAYMENT : PO ? R.O.OPENED ' R.O;'CLOSEp STOCK �1
34076\34076 CASH 29APR14 30APR14
OPTIONS: Options: DLR:VO ENG:3 . 0_Liter TRN:F6 AXL:32
N8T TOTAL
A TIRE, MOUNT AND BALANCE (2)
TIRE, MOUNT AND BALANCE (2)
Labor: 30.00 30.00
2 9004*15923* 225/50R17 156.34 312.68
PARTS: 312.68 LABOR: 30. 00 OTHER: 0.00 TOTAL LINE A: 342.68
34�76 REPLACED 2 RIGHT SIDE TIRES. HAND TORQL7ED TO SPEC.
*�,�-*ti�:******,t*******,t***#tw�c****�r*:**************.ar*�**,, ,
B PERFORM MIILTI;-Pp�Zq',� I1�SPECTION
''' PERFQRM MLILTI-POINT INSPECTION "'
Labor: {N/C)
TIRES CHECKED - OK (7/32 OR GREATER TREAD REMAINING)
Labor; (N/C)
BRAKES CHECKED - OK (DISC OVER 5NiM, DRUMI�I OVER '2MM)
Labor: (N/C)
TESTED BATTERY CHECK OK
_ Labor: ; (N/C)
PARTS: 0.'0 0 LABOR: '' 0.0 0 OTHER: �.fl b ' �`OT:ki, L�NE B: 0.0 0
34076 PERFORMED MULTI POINT
***:*�***********************************************
C** FAST LUBE (EMPLOYBE)`
FASZ' LUBE (EMPLOYEE) '
Labor: 5.00 5.00
'- 6 X05W20RSPrENGINE OIL 2 .61 15.66
°' Y 'FL*500'*S FILTER ASY - OIL 4 .35 4 .35
PARTS: 20.01 LABOR: 5. 00 OTHER: O.OQ , TOTAI, LINE C: 25.01
34076 LOF
*�,****,��********************************************
Note: If the wheels were removed during
thi� shop viszt., tY�� w�ee� Z�g z�izt� rieed to
! be r�-��r-t�ued 'in 5fi#0 rniles. '
D�S�#11PTkfJN>. 7D7AL5.
LABOR AMOUNT 3 rj . O O
-� � �.- - � � PARrs annouNT 3 3 2 . 6 9
��
` � � SALES TAX 2 rj , $']
,
s ,, ," SUBLET AMOUNT O . O O
, ;
WASTE REMOVAL O . O O
� ^�`����� MISC. � . ��
� � LESS ADJ./DED. O . O O
PLEASE PAY
THIS AMOUNT '�'�� . �36
Customer Copy
� r�..��'1���C ���;
BUYER IRUCKS MPLS .
2425 BROq[�idHV Sf NE
MINNEAPOLIS MN 55913
612�37u bu�i0
M�rchar.t ID: 65N�147�71H04
(�rm IG: 4534
Sale
VISR
XXXXXXXXXXXX3803
Entrv hethcd: S�iped
APPrvd; Online Batch�; 900�03
04�34�14 2�;25;2�
Inv�; 0�004007 Appr Code; 5$0202
iotal: 3 393.�6
Customer CoPv
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