Cleveland, Miriam NOTICE OF CLAIM FORM to the City of 5aint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
governing body qf the municipaliry within 180 days after ihe aldeged loss or injury is di.scovered a notice stating the time,place,and
circumstances ihereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing yonr answer to each question. If more space is
needed,attach additional sheets. Please note that you wiil 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 acknowtedgement once your form is received. The process can take up to ten weetrs or tonger 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 M i R j�M Middle Initial�Last Name ��£� �t-.A N Q
Company or Business Name R��E I V E D
Are You an Insurance Company? Yes N If Yes,Claim Number? _��ll �4 Q'��
Street Address l �3 3 � ���� �T��- � r'�TV �'`� ERK
City �� /�l� State �k Zip Code .�.���
Daytime Phone(� zlU-��Cell Phone(�SrZ)��- ��Evening Telephone( Sz 2/�-��
Date of Accident/Injury or Date Discovered / ` / �� Time b am pm
Please state,in detail,what occurred(happened),and why you aze 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 dama�e� ]� _�u�) /Vf�
�+'i M . 1"I
Cvuc.s� - ' �N 1
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Please check the box(es)that most closely represent the reason for completing this form:
O 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 properiy damage—please specify
O Other type of injury—please specify
In order to process your claim vou need to include couies of all applicable documents. I
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 propeRy of the City. You are encouraged to keep a I
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
"�'owing 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: medicai biits,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
Page 1 of 2 .
From: "Wolsey, Mary Lou"<MLWOLSEY@stthomas.edu>
To: "wkkrueger@prodigy.net" <wkkrueger@prodigy.net>, "dkkrueger@comcast.net" <dkkrueger@comcast.net>
Cc:"jmatchett@hamiinechurch,org"<Imatchett@hamiinechurch.org>
Date:Wed, 14 May 2014 18:21:36+0000
Subject: Fiction and Fellowship May, 2014 UPDATE
Hello once again to EDGAR VVINNER Kent and to Diane, directly and to our FicFel
group indirectly...
The gathering on Mother's Day, Sunday, May 11 provided a very good variety of
opinion despite a smallish number of participants (our meeting slipped through ALL of
the church calendar and notices slots, evidently).
Most were glad they had read THE WORK OF WOLVES by Kent Meyers.
Our Sept. 14 opening session for the 2014-15 church year [in all likelihood again at
4:30pm on the 2nd Sunday each month in the Parlor - unless other activities might cause
conflict] reading selection:
THE MARCH OF FOLLY: From Troy to Vietnam, by Barbara W. Tuchman (1984)
http:/Iwww.stoneschool.com/Reviews/IVlarchOfFolly.html
http:/Ijwa.org/encyclopedia/article/tuchman-barbara-wertheim
http://www.alibris.com/The-March-of-Fo11y-From-Troy-to-Vietnam-Barbara-W-
Tuchm
We learned that Kent Krueger's recent honor was a highly unusual unanimous decision
by the Mystery Writers of America judges in his category. See his blog about winning
the 2014 Edgar for best novel:
http://wi 11 iamkentkrueger.com/blog/?p=2$2
Be thinking of suggestions now for the October 12 reading and discussion to be decided
in September.
Among some titles which have been mentioned at past gatherings:
i
The Long Hard Winter of 1880-81, Laura Ingalls Wilder
http://en.wikipedia.org/wiki/The Long_Willter_%28nov_el%29
JoyLand, Stephen King
http://en.wikipedia.org/wiki/Joyla_nd_%28novel%29
The Vestments. John Reimringer
http://www,goodreads.com/book/sh_ow/7908490-vestments
junomsg://02C6B618/ 5/14/2014
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease complete this section
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 No U own (circle)
If yes,what department or agency? Case#or repo
Where did the accident or injury take place? Provide street address,cross street,intersection,name o�f P�ar�k or facility,
closest landmark,etc. Ple be asA etai�led possjhle. ff necessary, att ch a ' gram. (��� �4�K w,A-f
��H �I00 (r v,r'•��
Please indicate the amount you�e�seeking in compensation or what you would like the City to do to resolve this claim��N•
to your satisfaction.
Vehicle Claims— lease com lete this section ❑check box if this section dces not a I
Your Vehicle: Year��_Make 0 Model
License Plate Number State Color
Registered Owner
Driver of Vehicle �� �
Area Damaged S(,�,,( �S� %
.
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniur,�!Claims—please complete this section _ ❑ check box if this section dces not apply
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? es o 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
1�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 infor►nation 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 � �'� �s,i ���(
Print the Name of the Person who Completed this Form: O AN T IA.R'1'/N CL�u ECr�N A
�y� ' ' '
Signature of Person Matiing the Claim:
Revised Febrnary 2011
From: "Woisey, Mary Lou"<MLWOLSEY@stthomas.edu>
To: "wkkrueger@prodigy.neY' <wkkrueger@prodigy.net>, "dkkrueger@comcast.net" <dkkrueger@comcast..net>
Cc: "jmatchett@hamlinechurch.org" <jmatchett@hamlinechurch.org>
Date: Wed, 14 May 2014 18:21:36 +0000
Subject: Fiction and Feilowship May, 2014 UPDATE
Hello once again to EDGAR WINNER Kent and to Diane, directly and to our FicFel
group indirectly...
i The gathering on Mot�er's Day, Sunday, May 11 provided a vei'y good variety of
� opinion despite a smallish number of participants (our meeting slipped through ALL of
the church calendar and notices slots, evidently).
Most were glad they had read THE WORK OF WOLVES by Kent Meyers.
Our Sept. 14 opening session for the 2014-15 church year [in all likelihood again at
4:30pm on the 2nd Sunday each month in the Parlor - unless other activities might cause
conflict] reading selection:
TI� MARCH OF FOLLY: From Troy to Vietnam, by Barbara W. Tuchman (1984)
http://www._stoneschool.com/Reviews/MarchOfFolly.html
http://j wa.org/encyclopedia/artic le/tuchman-barbara-wertheim
http://www.al ibri s.com/The-March-of-Folly-From-Troy-to-V ietnam-Barbara-W-
Tuchm
We learned that Kent Krueger's recent honor was a highly unusual unanimous decision
by the Mystery Writers of America judges in his category. See his blog about winning
the 2014 Edgar for best novel:
I' http:lCwilliamkentkrueger.com/blog/?p=282
_
Be thinking of suggestions now for the October 12 reading and discussion to be decided
in September.
Among some titles which have been mentioned at past gatherings:
The Long Hard Winter of 1880-81, Laura Ingalls Wilder
http://en.wikipedia.org/wiki/The Long_Winter_ %28novel%29
JoyLand, Stephen King
http://en.wikipedia.or�/wiki/Joyland_=%o28nodel%29
The Vestments. John Reimringer
http://www.goodreads.com/book/show/7908490-vestments
1 of 2
r
._ � Saint �°aul P,olice Impound Lot, 830 Barge Channei Road, Vehicle Release Form
Make: 99 TOYOTA License#: 193JHU CN: 14139223 Invoice#: 151441
Date/Time Released: 07/08/2014 17:50 Tow Charge: $ 60.00
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: BECKY Tax: (7.625%) $ 10.68 ,
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 150.68 I!
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00 �i
Saint Paul Police Department. I acknowiedge I will report
damage and/or any other problems to the impound Lot staff Total Charges: $ 150.68
on this form prior to leaving the impountl lot.
Damage and/or other problem�
Police Report made� Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature siz000
C�\�:v-��� .
�
,� . .
� -,
S'T Pr��1L InPOUNU LOT
g;� g�RGE CHANNEL RG
SRINT P651-266�5692� 2450
Merchant 1��: 800638t1�`�'�
Term ID: �(7173990@�9@063N014908
Sale
zzzzzzzzzzzz6333 �{hod; Swiped
VISA Entry M
1ota1; � 154.68
07i48i14 iZ:50,39
In�� �: 0�0007 Apar Code; 010698
APPrud. ur�line
Customer Couv
IIiANh �UU'
. AAMCO
of Maplewood
TRANSMISSIONS
� � � � Tel: 651-777-4905
Fax:651-777-6450
TOTAL CAR CARE
1905 East County Road
TOTAL CAR CARE IXPERTS Maplewood,MN 55109
'2,,,,�� www.aamco.com
\�_J�
NI IQ
Hillcrest�Certified Auto
� �+���•��,��II�� � ���"��� � 1581 White Bear Ave PA�E '
St PauI,MN 55106
(651)771-0302
A
Create Date: 07/17/14 16:57:32
Customer ID: 0302022475 Year: 99 DatelTime: 07/17/14 16:59:42
Name: DAN CLEVELAND Make: TOYOTA Workorder#: 103595
Address: 1733 COTTAGE AVE E. Model: CAMRY Invoice#:
Address 2: Lic No:
City,State,Zip Code: SAINT PAUL,MN,55106 VIN: Email Address: no
Home Phone: (612)437-9080 Color: PO Number:
Work Phone: (612)- Engine: L4-2164cc 2.2L Fleet/Wholesale: N
Other Phone: ()- Mileage In: 0
Tax Exempt#: Mileage Out: 0
Salesperson:B.TURSSO
Service comments:
Qty Part# RFR Loc Description Parts Labor Total
MISCELLANEOUS
1 SUBLET REBUILT TRANSMISSIdN 2,250.00 0.00 2,250.00
2YR 24,000 MILE PARTS&LABOR
TOTAL MISCELLANEOUS: 2,250.00
***Customer Wishes To Discard Old Parts *'*
*
I hereby authorize the work described on this form to be done along with the necessary material and agree that you are not responsible for loss or
damage to vehicle or articles left in vehicle in case of fire,theft or any other cause beyond your control. I hereby grant you and/or your employees
permission to operate the vehicle described herein on streets,highways and elsewhere for the purpose of testing and/or inspection.Old parts will not
be retumed unless I specify specifically.
Signature
*
PARTS TOTAL 2,250.00
Date TECH: SALES TAX 160.31
LABOR TOTAL 0.00
GRAND TOTAL 2,410.31
THIS IS A WORKORDER, NOT AN INVOICE!DO NOT MAKE ANY PAYMENTS FROM THIS PAPERWORK!