Horvath, Jewels REC�lV�D
NO�'ICE OF C�.AIlV� FORM to the City of Saint Paul,Minne�� 15 ��14
Minnesota State Statute 466.Q5 states that"...every person...who claims damages from any nsunicipadity...shall cause to�i[�r�e�tec�ry�it��K
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of comperzsation or other retief demanded."
Plesse complete this form in its entirety by cleady typing or printing your answer to each question. If more space is
�eeded,at�at�lit�ena!sheets. Please aete that yon will not be contacted by tele�ne to elarify answers,so provide as
�nuch 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 sometlung dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCiTMENTS TO: CITY CLERK,
15 VYEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102
First Name v e W e-1 S Middle Initial � Last Name �O r v a}�
Company or Business Name ���
Are You an Insurance Company? Yes/No If Yes,Claim Number? �� �
Z' 2M St�� Add ss L�l rnaJ i r�q -(�'r-mnn M IJ -b �d�1tio.. . b�. c�-P�' t 5 . W 2� a�
1 t 1 a-5 �n s d a t e. S+• }� S
City �30�S E State l D Zip Code �-I tJ�a"� ��.{�(.
Daytime Phone(� � - Cell Phone(�2 )Z��-���4Evening Telephone(N�� - ���
Date of Accident/Injury or Date Discovered ��1 �� 2 d�� Time l�� YS I pm
Pleas�state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate wh or how you
feel the City of Saint Paul or i
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lease eck the x(es)that most closely represent the reason for completing ttus form: zw .
❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
��y 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
I]Other type of injury—please specify
In order to process your claim vou need to include coaies of all apulicable 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.
�roperty damage claims to a vehicle:two estimates for the repairs to your vetucle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims: legib e copies o any ic et issu an 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
�hotographs are always welcome to document and support your claimbut 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— lease com lete this section
Were there witnesses to the incident? Yes No Unknown (circle) /
Provide their names,addresses and telephone numbers: 2 �lfi l i-}t� V�1 DY�� �Ow�" � c�i'cl Ko�
-� fhe/'Y ha,vr�PS•
Were the police or law enforcement called? Yes No Unknown (circle)
ff 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 ssible. If necessary,attach a diagram.�,[• ��'1 S�'
inca di v�,o� e c�Sfi -a,�rx 25 �s b��Fa rc �Wu s�-�o r�l i a k.t- a+ uw. �t+�t -� L.�x�ircJ/an,M�
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your sarisfaction. � l I I •(�?� 'ThG -Iv�l arnotiw��- �v �(t��2C.�,r� -{��'P� •
Vehicle Claims— lease rnm lete this section ❑check box if this section dces not a I
Your Vehicle: Year 2oc�5 Make C�4 _ev Model C U��
License Plate Number `'S �_ State r�N olor Si l V C 1r"
Registered Owner wl'v�d a ��r v a-
Driver of Vehicle r J�-�
Area Damaged q � �1�XS � G �
City Vehicle: Yeaz Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
•u ��_ ��- �'""'�"'��""-�"°'° c ec x i �s secrion does not a I
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
a �.� P� �- )
�Check here if you are attaching more pages to this claim form. Number of additional pages '� �h.�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 complp+�� � 2 d � 'T
Print the Name of the Person who Completed this Fo eV��`S ��Y����" `
Signature of Person Making the Claim: ` �
Revised February 2011 "` ��^�I v—���
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T=R E $ A UTO S E RV =C E =N C
OWNED AND OPERATED BY A PROUD GOODYEAR INDEPENDENT DEALER �/RE&SERiflf�
10 6 0 8 FRANCE AVE S „��,,,x
BLOOMINGTON, MN 55431 -
(952) 884-9228 GOOD�`YEAR
FEDERAL TAX ID# 410978377 �DUNLOP
=NVO =CE 08/04/14 08/04/14 KE�LYI�TIRES
Z3Z5 Z4 lo: 02 � lo :29 Ar�t
TERR: 1667
PAGE: O1 NONSIG: 901667
BILL T0: JEWELS HORVATH �I Z '���� `���
2017 SOUTHCROSS DR
#707
BURNSVILLE, MN 55306
PHONE 1 . . . . . . . (612) 210-4784 EXT. VEH YEAR/MAKE. 05 CHEVROLET
PHONE 2 . . . . . . . VEHICLE MODEL. COBALT LS
DATE REQUESTED 08/04/14 VEHICLE COLOR. SILVER
TIME REQUESTED LICENSE/STATE. 888JPU / MN
RETURN PARTS. . NO ODbMETR IN/OUT 94976 / 94976
SI�L�SNIAIV. . . . . . 007 j Ou7 VEHiCLE INFO. . 2 .2
VEHICLE ID #. . 1G1AL52FX57591486 PRIOR INVOICE. 232033
ACCOUNT #. COB TC CUST# TYP-/STATE AUTHORIZATION CREDIT CARD P;�.
166700051 V O1 01782 0 MN 072413 HDC 2836
SLSM TECH PRODUCT COi)E BC QTY DESCRIPTION ?AR?S LBR/EXCISE LINE TOTdL
007 � 26e-004-8C1-0 R 1 195/60R15 88H SL �UN SIGNATURE II TL n?.:� C�� &i.>'4
��TY. 1 NC. PJRBLK1R3413
__ ___-....,- _.. _..._ _. _ _
0�7 C��' =�1_ZF3 R — NEW VALVE STEM 2.SC �0 2.:0
007 065 :�!-2h3 R 1 WHEEL BALANCE - C�MPUTER SPIN 1.50 10.�u i2. :u
007 065 ��;?-lll R 1 TIRE DISPOSAL 00 2.50 2.�0
V?S:T US ON THE WEB-VALLEYWESTGOODYEAR.COh' OE E.MAIL VALLEYWESTGOODYEAR@GMAIL.COM
IF VEHICLE 'AS ALUMINUM WHEELS & WERE REMOVED. LJG NUTS NEED TO BE RETORQUED WITHIN 25 MILES !
TIRE PURCHASE INCLUDES FREE ROTATION EVERY 6000 MILES
PARTS TOTAL. .. . . . . . 91.9�
LABOR TOTAL. . . . .. . . 13.00
ruAn��� AMO�NT 111.63 SUB TOTAL. .. . .. . . . . 104.9�
XCUSTOMER AUTHORIZATION FOR TOTAL =N V O=G E A\A3Lr AMOUNT 91.94 SALES TAX. .. ... . . . . 6.6G
TOTAL �'1 '1 '1 — 63
S E E R E V E RS E S =�E F OR I MPORTANT S A F E TY
WA RN =N G AN Q WA R RANTY =N F ORMA T=ON
HAVE A QUESTION OR PROBLEM't
. Please tell our store manager.We value your opinion as much as your
business.Should you need additional assistance,call our
CUSTOMER ASSISTANCE LINE 1-800-321-2136
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