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VanHofwegen, Daniel NOTICE OF CLAIM FORM to the City of Saint 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 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 information as necessary to explain your claim,and the amount of compensation being requested. You wilt 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 ///��EL Middle Initial�Last Name ��N ��=� �'r�/�'� fUIQ�i�y/ Company or Business Name�/� Q���I V E� Are You an Insurance Company? Yes� If Yes, Claim Number? N� u'^ �5 2Q�� Street Address -/ � �✓r" !(�F_ �J ,��] LERK City �/!�/��i���f State /`/�NfkJT�" Zip Code S� � �Phone (�) � -Z�Z P�11 Phone(�)�-�E�g Telephone(�)�S -23�"Z ,�S- U r�M�`s.��,'1 Date of Accident/Injury or Date Discovered L�'��� .� �� Time 6:� am/� 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 andlor responsible for your damages. � // � N ��' ��� i , Please check the box(es) that most closely represent the reason for completing this form: I ❑,A�Iy vehicle was damaged in an accident ❑ My vehicle was damaged during a tow 6�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 O Other type of injury—please specify In order to process your claim you need to include copies of all annlicable 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 are encouraged to keep a copy for yc�ytfself before submitting your claim form. olProperty damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds $500.00; or the actual bills andlor 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�ajury claims: medical bills,receipts �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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-alease complete this section Were there witnesses to the incident? � No Unk wn (circl,e,) J Provide their names, addresses and t�,lephone numbers: � (�t�i� -/39�`��"�/�,/�`^riTf��f, �j"Uj3"�� .,l�Q.rt �k- ��11� N�,��/IJ, rVl���T - �7-Zz0 -Sy13 Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? �- Case#or report# �A i � 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 de ailed a possible. If necessary, a tach a diagram. �fi.� F.�f�l3�M�`� - �i � J.Fn�,` �N S% ���'t- �tT �'nr� a' - /��/}'"k�"''T S� a��� Please indicate the amount you are seeking in com ensation or what you would like the City to do to resolve this claim to your satisfaction. � 69 . L�j i5 � � . u%o��-U " �i fl 'W/� � Cl Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year CU Make Model Gx IN il/ � License Plate Number State Y Color I.��lIC Registered Owner � l, N ' _�✓ f Driver of Vehicle i�L '1 � Area Damaged � �� � " �IT 1� r j i-�i7� ` l j S�,v�c%('��, City Vehicle: Year�-Make M Model �/�. License Plate Number State Color/1/ ����iss�S� Driver of Vehicle(City E oyee's Name)�/� Area Damaged 1U�� Iniurv Claims-please comulete this section check box if this section does not apnlv 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 i 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 processed. Submitting a false claim can result in prosecution. Date form was completed Print the Name of the Person who Completed ' Fo �"- �'� 1/ /k��� � kin the Claim: �`_� � �y1 Signature�f rers�n Ma g Revised February 2011 i Please state, in detail,what occurred (happenedl.and whv vou are submittin�a claim. Please indicate whv or how vou feel the Citv of Saint Paul or its emplovees are involved and/or responsible for vour dama�es. On the evening of April 28th, 2014, at approximately 6:00 PM I was driving my 2002 VW Passat wagon eastbound on Grand Ave. As I turned the corner in front of the apartment building at 510 Grand Avenue, my vehicle struck a MASSIVE pothole. The pothole was full of water so the exact depth and size of the hole could not be seen. Once I hit the pothole the entire car sounded as if it had just landed on concrete. I immediately got out and noticed that the front right, (passenger side), tire was blown. I had my wife and my 4-month-old son in the car with me. After making sure everyone in the car was okay, I went back to see what I had hit. The hole was about 10—12 inches deep, and was about 2 feet long and a foot wide with very steed sides and sharp edges. This turned out to be the perfect size for a car wheel and tire to fit in. After taking some pictures, (which I have attached), I went back to the car where my wife was also outside looking at it. t was about to get ready to change the front tire, when she stated that the rear tire was blown as well. I looked and sure enough it was. I knew at that point I would have to call a tow-truck as I do not carry two spares with me. After much research and calling around i finally found a tow company that would get there fairly soon and had the means necessary to two my AWD car back to Minneapolis, (this requires a flat bed truck). We were unable to make it to any of our plans the rest of the evening without our car, and I also had to call my sister to come from North Minneapolis and cancel her plans because tow trucks do not work well for car seats and 4-month-olds. After Roy's Service Center towed the car back to the house in NE Minneapolis we were about shot for the day. Our budget was running a bit tight,so I knew I would not be able to repair the car anytime soon. At this point I put on 2 spare tires from another car that I had and drove it awhile this way. I noticed that both the airbag light and the check engine light were on after hitting the pothole. When I had the funds I took the car to get new tires. The car is AWD so all four tires needed to be replaced as noted on the receipt by the technician. All tread wear on AWD vehicles needs to be the same depth to avoid powertrain strain and damage. After getting tires,the tire shop informed me that the rim was dented from the pothole; this is also noted on the receipt. I have included an estimate for the new wheel in with my enclosed documents also, (from Westside Service). I then took the car to Westside Volkswagen on HWY 100 to get the car an alignment which is customary given the new tires and the fact that I hit the pothole. We were leaving for a trip to Kansas City the next morning and I wanted to get all of the repairs completed before the long trip, (16 hours round trip). I was told that they would not be able to complete the alignment that night because it was a more difficult alignment than they were expecting. I was then told to pick the car up the next day and needed to take of their rentals for the night, (charged to me). The next day I arrived with my family to pick up the car. It was then I was told it needed much more work and parts and would not be ready anytime soon for a trip to Kansas. It was in need of over$3400 in damages. I had just had the car aligned less than 6 months before because I put all new suspension on the car, so I was expecting it would just need a minor adjustment for the pothole. We did not have the money for the repairs, and I knew I would have to work extra before making any further repairs, however, we had prior obligations to go to Kansas, so had to rent a car. We found the cheapest one we could with the time we had for$65 for two days. This allowed us to complete our trip. The enclosed repair estimate shows repairs for a transmission leak that was caused from bottoming out on the pothole, as well as repair for an airbag light that came on as a result of the jolt, as well as all of the other obvious damage to the wheel, tires, and suspension of the car. It has now been some time since the damage to our car. We are still unable to afford repairs to the vehicle, and our new tires have been running without a proper alignment as a result of this. Hopefully they will not wear out before we can get the money from this claim to get our car back into the state it � was in before we hit the pothole. All of the details of the damaged parts and the money it will take to fix �, the car are included in with this detailed letter and claim form. I did not get a second estimate because ' we always bring our car to the dealer for repairs and will not be searching elsewhere for quotes. We will 'I i get our car repaired at Westside. I I feel that the city is liable for these damages because of the extreme nature of this pothole. It was not ' i your average pothole. Also, I went online after the incident to report the pothole to the city of St. Paul. ' I visited the site www.seeclickfix.com. Upon visiting this site, I found that the City of St. Paul actually ' uses the site to help them respond to needs when it comes to potholes. I found several instances in which people who had hit the very same pothole had already reported the hole to the city months ( before I hit it with my car, and also for months after. I have included all of the report that pertains to ; the very same pothole enclosed. I have included copies of the incident reports on this site that pertain to the same pothole with dates ranging as early as March and as late as May for the very pothole that � cause this damage to my car. There are other drivers who say that they also are in need of filing claims because of this hole and also who have popped tires and had other damage. I also have heard from residents of the building at 510 Grand at the time of my incident who came out and saw what t happened. They stated that they pick up between 2 and 6 hub caps every day from the road where this pot hole is. I believe the City of St. Paul should have fixed this hole LONG before we hit it. It shows how negligent the city is for the care of the people driving on the roads and I believe it puts residents and visitors in serious danger to KNOWINGLY keep their roads in this kind of disrepair. It is dangerous to our cars, and also to our bodily well-being. It is because of this negligence that I am still driving a car that is ; not in a state of repair that it was in before I hit the pothole. The dollar amount of the damage would have been far less had St. Paul taken notice of this pothole when they were informed and made the proper repairs. Instead they let months pass and who knows how many people suffered because of just this one hole, let alone the complete disrepair Grand Avenue as a whole is in, given all the reports on other areas on Grand. The attached sheets show all estimates and costs associated with this damage. It does not include an estimate for all of the times we should have rented a car to prevent damage, it does not include the cost ofjust bringing the car into a one-stop place because I have done some of the , "shopping around" already, (for example I found a really good deal on tires, so I went with these as opposed to bringing into the dealer which was not having a sale), it also does not include labor for the wheel that was damage and costs associated with putting that on and taking the old one off, etc. It also does not include the ongoing damage that is being done to our new tires because we have not been ' i able to afford repairs as recommended. Please process this claim quickly so that we do not have to incur more charges for rentals,tires, etc. I trust you will do the fair thing. On a side note, some of the receipts show my name as"Daniel Sprik" or"Daniel Jay Sprik° instead of "Daniel Van Hofwegen" or"Daniel Jay Van Hofwegen". Both names refer to myself, as I had a name change late last year. To clear up any confusion I have enclosed a copy of the name change affidavit from Hennepin County. � Sincerely, I, �� � / I, � � �/�`��`� I Daniel 1ay Van Hofwegen ' ,II � �J �i�f� ��� '. Itemized Charges incurred to me because of pothole damage: (� � Tow from St. Paul to Minneapolis from Roy's Service Center: $ 119.47 Rental car for trip to Kansas from Enterprise: $ 62.22 New Tires from Discount Tire: $ 486.66 Alignment/Rental from Luther Westside Service: $ 199.39 Cost of new wheel from Luther Westside Service: $ 413.01 Cost of future repairs that have yet to be performed on vehicle: $3411.15 Total: $4691.90 ���tiZ�'� �J��✓"1� ��11 %t�I0�0�:�� 5�CL7�l�.Cr�+^ ��i01=� �,��5 Pu=t��S c�" �Il�� � C/� �I7 �� Oj" t�/��IIPn�. ��i�D�r �� N� ��� �I �� I �.�� ��,,._�,.�— ,.... �;� � �� �. _s� :" �9s��'�� '�a � �+ __ � >� �.� ���i w�§���� `�� � ,� *"' ���� � �� � �(d, �-� �� � � �' ��- �� �"2 ��., ,�,t. �� .. ..: ...;,.. r ::.... - �. :'.� .� .,. � � a� � . � �� �����'��; F � -�€� �. . ;� � �� � � � „ �, �. � � ';� +�r �- ` �, � �.'* . � �� „yn5��..`� -{ �:.:§,�,. � i' � '°„ � 2� k�C , � �� �'``�'�,.� �� ���� `6�s�" ,'*�'��� 7', .t� � P� �./, ^;£�:.,: : �f � 3 t .�u` F '?f i � ���f � ri I�i,i',� �I�I�I ,E�4"�)li � i. �f= s Y. �?�` -j{ II III � �� .�:'(� <f3�'�� � $ i � � i#'� � �.* „ . #�, 9� �+ `� .�.� ��.�"^. ,�hk �Y��� J4s, � x� .�s" �+' =z �„f, �'. �R 4 �`��d�` f. -d. ✓,k: s� „ � � ��� ����� � r ����/ )� � ��'i� ;'�� +�e1i �rv� fiKrtS;i `3 &; .�f� "�4��'�,Y P�"�'�' � � � � .�,y r 'i � . -�... �$�d .« � � � � £ ���`� �� ��'fi � �.: � . �i� � 3 y � Y��.y�,, ., S � � �Y � �.: ....,-.._. .� ... , ,<_ ,,.,_ � I � � j .. . . � �- �'. f� I �q I . �. .�' -. .. .. .. ,:.. ��.. � . 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YE3 NO Vtv� t, �±�,�� ,A��� DESCRIPTION: t V���E�e� � IE�i�,J�:�.BY MY S!�!��RE�OVUt OSED BY HAIL DAMAGE7 YES Na TMAT 1 iiA1c� . A�11t�R��N��T��M+�E+ I�O^VnE NOpTiC,E� IN��G��n,t��v�EDn/�INN�TH��SEpP��ARRIE�Fn(�ciN) ��io ev CA�.SH- CHE 14, _. CMRR( F OUT E 1/8 1/4 3/8 1/2 5/8 374 7/8 F� �D � ���`�J���W�J�VIY��/'VVY117C YYNVCR�1-VNYI��("AVL�. �.. . . � . '.. � ��. ��. E i_.: !.t,_ ,li:• � 'i :;�t_?t ?:i � �, RECEw�'OF , DkTE AI�AOUN1' RECENED � W C11 1/4 V 5!�� A.. B..�F�� . t� � . C.ASFiREFIJND . � )W1VER�S AN AFFILIATE OF ENTERPRISE HOLOINGS 1tJC.,W I pWNS ALL RIGH7S 70 EN'tERPRISE NAMFS AND MARKS, ,�---�-- _ cp E�erprise Leasing Company of Minne�esta,LL.C,� � � � ..�. (.3�. �. �. � �xEl.3� dT.�`fG �n4it . � .' ��.......,. .:_.....,..._r . D���ouNt� ��� T 1 R E ���E i �� � ��a�s�� discounttire.com �EF�ftIiVT o��� INV #J�70JJJ7 DRIG DATE 05—`1-2�14 Df�T�: 05—�1—�Q�f4 TIME: 6:4� �'M . .• . .- . .- . . DANIEL VAiV HOFWEGEIU �@Q�2 UW MN�1 1 f 139 14TH AVE N RASSRT 528� CENTRAL AVE IVE ALL GLX V6 COLUMRIA HTS hIN ��4`i ;Y1 I rJhdEAF�OL I 5 M!V 5541,� M I LEAGE: 150,+��Q� F'HONE: 763-571-0566 ;k-i) ba 1—�s85—�38` L;?3 AlVTHOIVY W LARSEN I I TD�tQUE SF'ECS: �9� WORK ORDER# •. . . . , �:6955 MF6 —� �iJ��FJFS.7 91W ASW CDNTI EXTREME CONTACT DW .+�0 65. �0 —13�. �� CQMMENT: POLT F�ATTERN: 5-11� � 4�•6L7 NRM � ��5/45R17XL 94W BW YDK YK58Q� .�iQ� 1�1. �Q� �4�.�� WARRAlVTY: h1ILEAGE— 45,��Q� SEE REVERSE 5IDE FOR WARRANTY DETAIL5 COh1ME1VT: I NFLAT I QN F:30 E2:30 !, 8��+17 NRM � CERTIFICATES FDR REFUND, REPLACEMENT .Q�Q� 16. @0 3t. �� I �u4��,:� iJ�iM � ADJUSTMENT LI�ETIME PALAIVCE & VALVE . �Ii� 16.Q►� sc.�� ', -��a�7 PdRM 4 �L�/45R17KL 94W RW YOK YK58� . Q�Q� 1�1. Q�►� 242. �� I �ii�,�RA�!T`r; �1ILE�l�E— 4�, ��� SEE REUER�E SIDE FOR 't+iRRRANTY DETAILS i �.:Oh1C�iEPi�: it�Jf LHTION F:3� R:.3� =;t�17 N�t�! L CERTIFICNTES FOR REFUlVD, REF�LACEMENT . �� 16.��+ 3L. �+� ��h��4 iVRM 1 WASTE T I RE D ISRDSAL FEE ,�� 3. �� �. �� 8��19 iVRM ; INSTALLATION R� LIFETIME SF�IN RALAiVCING .Q�� 16. 0� 3c. �� x�4�� NRM ` VRLVESIR[lTATIDN5l LIFETIME REF'ATRS IIVCLUDED .�0 .�0 . �+�A � ��13E IVRM —1 TRADE—IN TIRES TRADE—IN TIRES .�Q1 �0. 0d� —�0.��s CDMMEPJT: replacing the two because of pot—hole damage, one of the wheels is slightly ! CDMI�ENT: bent fro� the pothale damage. all fo�m tires need to be repl�ced because CO{+1h1ENTe of thE all—wheel drive system of the vehicle. �, �7417 NRI� 1 �75 BEST �E/�7/14-06/�9I14 .�0 . �D� , k�� �i gnat�.ar�e an f i 1 e �� i ooa� recydable papei v�s�ou�t� � TIRE RAC7E 2 QF � JGBJJJE� discounttire.00117 ���'RINT ORIG INV ttJ�Q�JJ7 QRIG DATE 0�—;�1—�014 DATEe �!`—�1-2Q�14 TIME: 6:42 F'M . .• . .. . .- • . Iif�NIEL VAhl HOFWE6EN 2Q��� VW MNM I1 1�;9 14TH AVE N F�ASSAT 528� GENTRAL AVE !VE ALL �LX U6 CDLUMPIA NTS MN 554Li !�I NIVEA��DL I 5 MN �5413 M I LEAGE: 150,OQ�� PHONE: 763-57 i-05E� �;Nl 631—�85—:38� ;�,s ANTHD�lY W LAR5EIV �I TORG�UE SRECS: �9Q� W�RK ORDER# .. ,, � � � I her�eby certify I am the owner af the product presented for, warranty clai� �nd the product described was not involved in any �ccident, personai injury, consequential damage, or ather, ioss. I �ccept this adjustment credit in li�u of other claims. T ag�^ee the product returned for replacea►ent beco►nes the praperty of the prod�.�ct man�.�f�ct�{r^er-. i ihE tir-•e and/or wheel yo+_� h�ve choser� is differ•ent fr•om tl-ie arigin�l equip�er�t pr-ovided wi�h ��� yo�_ir vehicle and may change its handling or st�bility characteristics. I �=urther, infor�mation is available fra� yo�ar Discount Tir�e s�lesperson. ' I I i ; SURTOTAL: 46�,. �� TAX: 3v;, 07 TAX(REFUND) : —�a, 41 TGTAL: 48E.�, 6E� XXXXXXXXXXXX 3965 VISq; 4�tE,, �� TEIVDEREUe 486� 6�� Signature on file ��� i oo�� luthe Westside - -� Volkswagen ��' 2370 South Highway 100 S#. Louis Park. MN 55416 Ph: (95`�} 377-4100 Fax: (952) 374-0755 ww�N.we sts i d evw.c o r-i CUSTOMFR NO. ACT/ISOfi TAG NO. INVOICE UATE INVOICE NO. � 64043 TRACEY SCHRUPP 716 4449 05/23/14 C5425046 i -------------_. ._____ _- --- ---- --- ------- --�---- --- --_ —__-- 1 l AHUF�RAi E I LICENSE NO. MILEAGF 1 COLOH C CK M1C: !. DANIEL SPRIK ,zK995 160,492 �vHITE/ , j 139 14TH AVE NE ______--�-- ____...---____ �_--- _ v--- �--__ - - r _� . . - __—._ lo��.IJ,G., �.F.�", tLVrfYDil ' `MPLS, MN 55413-1060 EAr�'NAKE MODE. / - / D_LIV H�A E/ � ' - d2 VOLKSWAGEN PASSAT WGN GLX 2 S 4AT O1 O1 O ,W���vW�YH63 B02E197 544 , __ __ _ _ _ _ - ___ _ .:- : _ , : .. ,�;.� _ , ,,-. daniely.varv.HOFWEGEN@gmail .com 05/22/14 __ __ __ ___ _ ____ _____ _ ,�q�y� ,{��ry� _.___._ _ . y �Fl�1LEfSZS�-2382 i'_aus�yFS., .ior�� tE�p�r,^'�.8_LITER MO: 160495-. 3F ---------------•------.----•--'•-._._...---•--------------- We beiieve in follaxi^.� certair a!incipie> :v!�. . interact wfth others.Our bahavior should be�re^ectioo; JOB# 4 JOURNAL PREFIX UWCS JOB# 4 TOTAL 0.00 of these principles: i feimess human digniry pntentia! f MISC------CODE-----•--DESCRIPTION-------•-•---- CONTROL NO--------- �ntegrrry service 9rowm ................. JOB �}' A S$ S ENVIRONMENTAL DISPOSAL 15.37 These principles can be translated into practice:;whir,h) TOTAL MISC 15.37 guide us in our interactions with other people. ;�We are fair.We cleaAy state our expectations.We do� �� not intentionaily misrepresent ourseives or ouri ESTIMATE-•----------------•-•-•--------••---------•- P��a��ts. ; CUSTOMER HEREBY ACKNOWLEDGES RECEIVING ;"�We keep prbmises ard fulfiH expecfations. � '� ORIGINAL ESTIMATE OF $200.01 (+TAX) ; i we treat everyor.e .vith resoeot ai�d cc�r :<�. v^:,•:' I COMMENTS------•••-•-----••--•-•---------•--••--••---••-----••-----•-•----••----•---- ackr.axlodge and gr�et every_ person_We �u���svre:�' � WAIT CCC Appointment created 2014-05-21 07:18:OOpm taken by Cchles r!,<� ,�-i�Fn���� '� :+ r��A���j�v ������� �,�� ,<, " � $UddUth-H81'Pl5 companyordepart �.e i nar.�c �ani:ou �n ��<_. � ' YVe are uncrnd:•�.orA��y af,e�,�.�a?�_..,���..__...,. � TOTALS---•••--••--••-•--•-•-•-----------•-••-•------------------•------------------•------••---- � ccnm���tes „ ,,er. '�^dc �,cr.:, ��PPcrtunity to . � servi.c *********,r***********�x****�x****,�**,t***�r*******�-x�x****�rx TOTAL IABOR.... 153.E)5 , 'we respec!�iie r r�--,,r- �c �� d�> �� �. I TOTAL PARTS.... O.00 �r imenticna�l� ar aye�h�env�romm � Thank you for sel ecti ng Luther Westsi de Vol kswagen for your TOTAL SUBLET... 0.00 '�'NQ beliove that everv porsu� ha5 �o�� .�.� . , provide oach other with ar, en�ironm .^, tt��t� � service needs. You may be receiving a survey from the TOTAL G.O.G.... 0.00 oncourages 9ro�cn a�� ae�eioPme�t. .���� ���; manufacturer i n the near future. We would appreci ate you TOTAL MISC CHG. 40.37 patient with others. j taking a few moments to complete and return this survey. The TOTAL MISC DISC 0.00 �� i ; i nformati on i s very val uabl e i n hel pi ng us to improve the TOTAL TAX...... 5.37 �. Keep a C',reat TninK Go:ng ; service we provide to you. If you have any questions or •-•--•-- � Genuin�vw Pares R Ser�ice � concerns, please contact us at (952)377-4100. TOTAL INVOICE $ 199.39 ; *********,r******,r***,t�x**��x***�r*,r****�x********,t:t�r****** STATEMENT OF DISCLAIME+? � �Vi si t our web si te at www.1 utherauto.com or our Facebook The factory warranty constitutes a!! >f�"�; Ipage at www.facebook.com/1 uther.auto.deal ershi ps for speci al warranties with respec;to the n� � � :- offers, contests, videos and more!! litem!items. The Seiler hereby Px �:, . disclaims ail warraniies. either ext;...�. . impl+ed, includir,g ary impiirci�,�ra�r;r`,�; ' m�rchantability or fitness �c�r a par5c;ui�3;' purpose. Seller neitt;er assum��s rn�;r�� authorizes any other person to a,sumn, for it any liability in connectioE} w�1h the; _ sale of this item/items. � ALL PARTS NEW ORIGINAL EQUIFMENT+ UNLESS OTHERWISE SPECIFIED. � i j ,; -------------—________ _ _..; CUSTOMER SIGNATUR[ 'I �� � ' � � ,�I i c PAGE 2 OF 2 CUSTOMER COPY [ END OF INVOICE ] 08:38am I i �i Luthe Westside ��� Vol�cswag�n `�►= 2370 South Highway 100 St. Louis Park, MN 55416 Ph: (952) 377-4100 Fax: (952) 374-0755 wv��w.westsidevw.com cusroMF��No �n�visnH Tnr,r:o. �����,�oicE��a `� — �i >>�.� �, � G4O43 TRACEY SCHRUPP 716� 4449 05/23/14 Vw�5425046 — _ ----- ---- __ ___ ; . , ,,, __._ --- _ ___ ___ _ _ .. ..-. �P �1GE .__ DANIEL SPRIK �ZK���` � 160,492 �vHZ�TE/ �__ _ __1 .-- � - t _ _ . --- _ 139 14TH AVE NE ��AF, f1AKE MODE� I��ELf EHY A E � � ��� ` • MPLS, MN 55413-1060 �0�/VOLKSWAGEN/PASSAT/WGN GLX 2 8 4ATi �1�01/02 ; ---- -------- -- —__ � �Wh�iIC�I_WN Y � � � B � 2 � Z � � � � � SEILING D6ALFR NO �4 f40DJGilON�AT� � i + �--- ------- -- -------�----- ____�___-----_ __- ----1 daniely.VAN.HOFWEGEN@gmail .com IFT` rJ" j��\�� L���/22/14 I --1----------- ---------..:---------.____---' qe��Er�+�-2382 ___ Igus�Nessv�oNe —__--��°�'""�''L.S8_LITER MO: 160495� ..--------'---•---•--•'---•--------'--••---•----...-•-----------------------•.... We belit�ve in foilowing crrtain princiaic^ wh:.�r wel interact with others.Ow behavior should t�e�re��lF;r.±ion, ��R-----•----••-•----------------------••-•-•-•-------•••---------"--•---------- oftheseprinciples. .. ,}# 1 04UWZZ4WA 4 WHEEL ALI6NMENT TECH(5):120 134.95 �airness num i� di��i it� F�o n�, , CUSTOMER REQUEST 4 WHEEL ALIGNMENT DO TO HITTIN6 A POTHOLE «�rF� �r �E-r�r� a�w•� ON THE RIGHT HAND SIDE OF VEHICLE. Thes� �nn G�es � ti � i t + n . PREVENTIVE MAINTENANCE �uid�ii n cu�mt �� ��a t �t� �, �� I PERFORMED COMPUTERIZED 4 WHEEL ALIGNMENT SERVICE. ADJUSTED ���wc are+ai� N� �rary .< < < .<;�ct � � - FRONT CAMBER AND TOE.RIGHT FRONT IS BENT AND NEEDS STEERING �-� �tcntinnai �,; F�u�. � .t croducts. KNUCKLE AND BEARING.REAR WAS ABLE TO ADJUST CAMBER BUT BOTH ;�ve kee�promises ao�a ti�e! �ape:;tatons REAR TIE ROD$ ARE SEIZED,CUSTOMER IS GOING TO HOLD ON ANY ' w�treat everyore Nu 5�r�t a��y �oi;�n ;v.'�,,::I FURTHER REPAIR AT THIS TIME.E acknowiedge ard greet every ne�so�. �v� ai�s��e�, ��R 134.95 .-: /ve P e uncondi o���ytot ser ae�to ouociv--�g thej the tele hone r, 2 fnendi manner, ! OB# 1 TOTALS--••---•-•-----•---•••--•---------------•---••----•--••--- i��.ame ! '� i.�`omers, communities and each o?her. �N� wriw��.ne the JOB# 1 JOURNAL PREFIX VWCS JOB{� 1 TOTAL 134.95 opportunity to be of sorvice. ; j IJ�� Z CHARGES-------------•-'--------...----------•-------•--•------...--------'--•----•--••-- L-'WerespecttheemironmentWeduno±litter �:ofu�e; �, or intentionally damage the environment. i ��. �2ROOUWZZSOF--••---SYNTHETIC OI L CHANGE--------�---''� TECH(S):120-•-•---------•-- 18:��70 �� P c�d�ge80 gaov�r��nd���d��vF����n o�t�� �� � '� �� PLEASE PERFORM OIL AND FILTER CHANGE. CUSTOMER HAS OWN �atier:Nmnom���s. PARTS IN THE REAR HATCH OF THE VEHICLE. °. i PREVENTIVE MAINTENANCE. � Keep a�;reat l�hin� r ��n� REPLACED ENGINE S 0 ND REPLACED °�'�',�� c;�;,�,;t,�ti`�� i>�;", ` ~ " � OIL FILTER. � i , ..<,�. ._ __.,__ _ .... . . ' i OB# 2 TOTALS--•-----------------•----•-------•-------•--- •------�BOR 18.70 STATEMENTOFDISCL.AIME' � The factory warranty constitutes aN�f tr.�,l � JOB# 2 JOURNAL PREFIX VWLS JOB# 2 TOTAL 18.70 warranties with respect to the sale �i this' I OB# 3 CNARGES-...---•------•---•--•-----...--•----------•---•••-----••••-----•--------•------- item/items. The Seller hereby ex�.ressiy disclaims all warranties,either expr�ss or � -----•-----•---- im lied, includin an im lied w2rr�n of OR•------•----•---•- ...----•-•--• ------••------•----.... P 9 Y P� tY 3+45VWZZRENTAL RENTAL•GUSTlEXT''WARR 7EGH(S):120 ��`��` merchantability or fitness for a pa*icular � CUSTOMER HAS BEEN SUPPLIED WITH A RENTAL VEHICLE. purpose. Seller neither assumes nor RENTAL VEHICLE. authorizes any other person to a,surr;e; ISC---••-CODE---•----DESCRIPTION••----••--••----••--------•••--CONTROL NO----•••-- for it any liability in cannection w th tt;e i RC RENTAL CAR-CUST PAY/EXT WARR 25.00 sale�f this item/items. -,j TOTAL - MISC 25.00 ALL PARTS NEW ORIGINAL CQUIF":�_'�" �� UNLESS CTHERWISE SPECir=1EL� � '�JOB# 3 TOTALS----------•--•----------•---------•--••------•----------•••- � MISC 25.00 � )� JOB# 3 JOURNAL PREFIX VWC$ JOB# 3 TOTAL 25.00 � �� ,MF�;r;�,�ti.:ui:e JOB# 4 CHARGES-----•-••--•-----•-----•---•-•••-•-•-•----•----•------------•---•----•-•------. (_�":� rLABOR--------•---•--------•-•-----•------•--------- -----•-----•--•---- , -,J# 4+22VWZZEFR FLUID LEAK-RED TECH(S) 120 '�'��� � „ WHILE PERFORMING YOUR VEHICLE INSPECTION WE FOUND A i CONDITION RELATING TO ENGINE AND/OR TRANSMISSION FLUID LEAK(S) THAT REQUIRES ATTENTION. I SEE YOUR ADVISOR AND/OR MULTI POINT INSPECTION FOR DETAILS. � PAGE 1 OF 2 CUSTOMER COPY [CONTINUED ON NEXT PAGE] 08:38am Vork`Order: 425046 ��.,�..«�:,, .,-.-. (ll II I��I II Ifll I II�IIII'I II I�I�'II II I"II'I IIII��I'�III irst Name: DANIEL ' WVWYH63802E197544 ast Name: SPRIK .icense: ZK995 'echnician: #120 )dometer: 160492 tate 5/23/14 7:25 AM Volkswagen 2001-05 Passat 4X41 BA ET37 Before Measurements Left Front Right Front �' �� _ ��� � Camber Camber ' �� �� ' - - l` ���1 I' Caster � '� Caster � Front I ' i i �-�� �•,, e � i ,�� /'i• T'gi�✓� i � . �'�� Toe ! Toe � ' 6 ; Total Toe � T I � ! 5teer Ahead ; i Left Rear Right Rear ! i - 'ti, � � � � I j ',� i • . =i • . I �H � Camber - -- Camber .,E Rear � � �• i ��i i{r� � . , o-�� 1 • � � , • ' �''W+' i �{.� I I—I Toe j� Toe i Total Toe I i � i f• . � ' i i � Thrust Angle � '�-- ' Current Measurements � Left Front Right Front I ' �'� �� � � �� i � • . . ; i - � Camber Camber � .�; :; 1��1� � �� ����1 ti,, _ �, ' Caster �' Caster � � Front )( ifh'4tr`U� �• � � � � ,�y-= �' �. '�F'd;'�' � , Toe, �L'lr��`� Toe i � Total Toe I � � X I I i / ' ' � � � j SteerAhead Left Rear Right Rear i ; ,� � � ', �- Camber -- - Camber � a_ i ; o- e,., , Rae� , , , , : I'I.1 � • � �,,f � ' • ',,Ti Toe �1=-,� Toe � I� � Total Toe ' � j .I t `• ' , � — � �---.---- ThrustAngte � One or rreore�air�es are not within specific�tion. Tire wear, handiing and safety prob►ems may resuft. 'ork Order: 425046 �II 'I�'II'I I��I��I����I'I II I'�I�II'I I'��I'� III"�I'� 'II rst Name: DANIEL . WVWYH63602E197544 �st Name: SPRIK cense: ZK995 =chnician: #120 �iometer: 160492 �te 5/23/14 7:25 AM Volkswagen 2001-05 Passat 4X41 BA ET37 Before Measurements Left Front . Right Front 1� � � � '1 1 '' , .� . 1 ' � , 'i � Camber '� Camber , � v� - , � � r' � � � ~ ."!�V . . L� .:, • ��- • � �- Y��__' __ w ..:x •A'•: Caster '�' Caster Front �� �. � � � � ' � � � �� 1 • 1 . r � i � 1 ' / ' I� Toe � � `�" ��' Toe � Tota I Toe v v � Steer Ahead � Left Rear Right Rear �, � . � • � �• � 1,`� s r � • � � 1,, i . ; Camber �� Camber Rear ��� �. ,• �•� , . . , � ' 0 G L a p � '" Toe Toe Total Toe �• � �• � � ' • Thrust Angle __-------___________ --- ---- _ .-- __----- --- One or more values are nat within specification. Tire wear, handling and safety probfems may resuft. � Quality Vehicle Inspection Customer Name: DANIEL SPRIK Vehicle Year/Model: 02 VOLKSWAGEN PASSAT Date/Time:05/23/2014 08:38:11 Phone: (H) (612) 385-2382 VIN: WVWYH63B02E197544 Odometer: 160492 Service Advisor: TRACEY SCHRUPP Technician: )OE R0: 425046 Tag: 4449 WILL REQUIRE FURTHER ATTENTION Green Yellow Red � � Washer fluid '� � � Brake fluid LF RF Power steering fluid Green Green � Coolant ❑ Yc���W ��I�W ❑ Red Red �'��',1` � Engine oil � ADBIUE Fluid � Inspect Headlights, Parking, Interior Lights �R RR � Inspect Stop, Backup and Turn Signal Lights Green Green � � Inspect Wiper Arms and Blades (includes rear) ❑ v���ow ���oW ❑ Red Red : � Inspect Windshield for Damage � Inspect Coolant Hoses (Radiator and Heater) ❑ ❑ Inspection Not Taken Inspect Coolant Condition (temperature protection) ��� � Inspect Engine Drive Belts (condition) � 3-7mm(Disc) 1.01-2mm(Drum) � Inspect Brake Hydraulic System ` � � � Inspect Engine and Transmission for Leaks Comment ATF PAN GASKEf LEAKING � � Inspect Front End Linkage �F RF Green Green � � � Inspect Struts/Shocks for Leaks � Yellow Yellow � � � Inspect CV Boots and Drive Axles � R� Red � Inspect Exhaust System for Damage and Leaks � Inspect Pollen Filter and Air Filter � � Reset "Maintenance Reminder" Light LR � � RR � � R2S2t TPMS Light � Green �reen � ❑ � Yellow Yellow � Multi-point inspection has been completed Red Red ;;ra General Comment: AIR BAG LIGHT ON REAR TIE RODS SEIZED �r, -�; 4/32"to 6/32" .� Good ❑Fair Bad Actual Cold Cranking Amps � Factory Cold Cranking Amps � RENTAL AGREEMENT westside q�'�"'"'` ,�S�`��' N Yol kswa�en St. Eouis Park,Mi�t 554'!6 ``� Tei.{454)377-4'I00 26580 CUSTOMER NAME PHONE REPAIR ORDEF N0. Daniei Hofwegen HOME ADDRESS VEHICLE NO. 139 14th ave ne N/A WVGBV3AXOEW505432 CITY STATE ZIP LICENSE NO. MPLS MN 55413 426MKY DRIVER'S LICENSE NO. STATE EXP.DATE O.O.B. YEAR-MAKE B012057135403 MN 09/02/2015 09/02/1982 2014 VOLKSWAGEN FIRM NAME(EMPLOYER) MODEL COLOR TIGUAN GREY ADDRESS cirv STATE ziP DATE DUE IN TIME DUE IN LOCAI CONTACT and/or ADDRESS PHONE AM 05/22/2014 os:oo Pnn OTHER AUTHORIZED DRIVERS ODOMETER IN I� DATE TIME AM Only the persons named below are authorized as additional drivers: PM N D.O.B. ODOMETER OUT NE 9614 QUT 05/22/2014 10:01 pM DRIVER'S LICENSE NO. MILES DRIVEN N�NE D.O.e. RENTAL RATES CHARGES DRIVER'S LICENSE N0. O.00 MILES @_ ¢ $0.00 CUSTOMERS AUTOMOBILE INSURANCE INFORMATION cns COMPANY NAME Pcll iGV nln OUT W HOURS @ $ E E 1 DAYS @ 0.00 $0.00 VEHICLE CONDITION �i4 ii4 ouT iN IMPORTANT ii2 v2 WEEK END @ $ Fenders Body 3/4 G�ass •READ CAREFULLY ALL PROVI- F F WEEKS @ $ eumPe�s SIONS ON REVERSE SIDE. roTA�rinnenrvo Tires •CUSTOMER IS RESPONSIBLE MILEAGE CHARGES $ wnee� FOR ALL TRAFFIC VIOLATIONS. SA�ES rAx $0.00 covers •CUSTOMER AND/OR CUSTOMER'S INSURER ARE Grill RESPONSIBLE FOR ALL DAMAGE OR LOSS TO MINNESOTARENTAL $0.00 �'gnls RENTED VEHICLE. SEE SEPARATE CONSUMER VEHICLE TAX Too�s PROTECTION NOTICE. N��NNESOTA 3% g 0.00 SpareTire REGISTRATION FEE �ignter •DEALER DOES NOT PROVIDE INSURANCE COVER- REFUEUNG CHARGE $0.00 Radio AGE FOR THE RENTED VEHICLE EXCEPT AS RE- Upholstery G�UIRED BY LAW. TOTALCHARGES $O.OQ Sea�Speedo •CUSTOMER AUTHORIZES DEALER TO PROCESS A warranry CREDIT CARD VOUCHER, IF ANY, IN CUSTOMERS �ESS DEPOSIT(-) $ Manua� NAME. Cnecked •CUSTOMER MAY BE PROSECUTED IF VEHICLE IS BALANCE DUE $0.00 By NOT RETURNED WHEN DUE. (CASH REFUND) $ METHOD OF PAYMENT �CASH ❑CREDIT CARD ❑OTHER CUSTOMER HAS READ BOTH SIDES OF THIS AGREEMENT AND AGRE T LL P�ISIONS CREDIT CARD COMPANY EXP.DATE AUTHORIZATION AUTH#: X _�.,.,;'� -Z U �. USTOMER'S SIGNATURE CREDITCARDNO. EXTENDTO , ADdITIONALDEPOSIT DATE INITIAL XXXXXXXXXXXX � TERMS ARE STRICTLY CASH OR CREDIT CARD UNLESS CREDIT APPROVED BY: PREPARED BY: APPROVED IN ADVANCE BY DEALER LOR LUE NOTfCE: Under Mir�nesota Law,a personai au�omabile insurance poticy issued in Minnesota must cover the rentai of thls motor vet�icle agatnst dar�age to ihe vehicle and ac,}ainst (oss of use af the veh�cle. Therefore, purchase of any eall�sion damac,� �aiver or simitar insura�ce a�fected in this rental contract is not necessary ff your po#i�y v�rss issued �n AA�rtnesota. Customer acknowiedges that�he above Notice was read and understood. , f:. , , _ �� � �`�� � y , _ j�j. t` .y - F,i� �i.:� , y, z �;.�`<� cE � �f�'' r Signature Date #CDW Reorder from: MADA Services Inc., 200 Lothenbach Ave., West St. Paul, MN 55118 RENTAL AGREEMENT Dealer agrees to rent this vehicle to custamer subject to the provisions of this agresment. 1. AUTNQRlZER BRlVERS. The vehicle may be driven oNy by Ehe cusfamer and other licensed drivers named in the front of this agreement. Customer agrees not to permii any other person ta drive tfie vehicie. �. USE OF VEHlCLE. The vehicie must be operated in accardance with law. It must not be driven in a negligent or reckiess fashion or in any race, speed tesi or cantest. The vehicle may not be used to transport persorrs ar properry for hire nor to ��.�sh or tpw any vehicle or trailer. The vehicie may nOt be taken more than 50 miles from the dea#er's place of business or out of the country tiviihout the dealer's written permission. "s. �ETURN OF VEHICLE. Cusiomer agrees to relurn the vehicle in its present c�ndition • norma! wear and tear excepted -ta the deater on r�r be(ore the due �ate and time shown on the iront of th�s agreement or sooner ii demanded by dealer. D�afer may peacefully repossess the vehicle, withoui �emand, wherever found if the vehi�le is illegaily parked, is used in violatian af law or this agre�m�nt, is apparently abandone�, or was obtained as the resuf2 of any misstatement or fraud. Dealer sha11 not in any way ba liabie to customer for damages resulting from such repossession nor shal( it be responsible for ihe loss or damage fo any property of customer in the vehicfe. -. AMOUNTS DUE BEALER. Cusiomer agrees to pay dealer: (ai All time and mileage charges as computed on the front of this agreement; (b) Refueling charge if�ehicle is returned with less#uel than when rented; (c) Appiicabie taxes: (d) Ali fines. penaities, forteitures,court costs and out-of-pocket expenses incurred by dealer with respeci to customer's use ot the vehicls including parking, tratfic, ar other violations assessed against dealer, the vehicle or customer. (e) Deaf�r's eosts and expenses,inc(uding reasonabfe a#torney's fees incurred in collecfing the charges due or in repossessing the vehicle; (f) Full vafus of any loss or damage to the rented vshicle, regardiess of fault,including dealer's loss ot use; IMPOFiTAN7; IF QAMAGE TO RENTED VEHICLE IS COVERED BY THE CUSTOMEf�'S lNSURANCE, PAYtVIENT BY THE iNSURANCE COMPANY WITHIN TIME LIMiTS PRESCRi$Ep BY LAW IS AGCEPTABLE. PRIOR PAYMENT BY THE CUST4MER fS NOT REQUIREQ. 5. VEHICLE INSURANCE. Dealer does not provide insurance coverage for {he rented vehicie except as required by Minnesota law, Any insurance carried by dea{er on rented vehicle in accordance with Minnesota Law or o#herwise, shal! be applicable on1y after ail other v31id and collectable insurance has been paid to their futl limits. Customer indemniiies and holds dealer harmless for all loss, liability and expense in excess oi dealer's insurance lim'ris provided for above as the result o# bodily inj�ry, death, or property damage arising from the use or operation ot the vehicie. Customer or customer's insurance is respansible for aN damage or loss to the renf$d vehicle, regardtess of fault, including dealer's foss of use. 6. NO AGENCY. The vehicle is the property ai the dealer.This agreement is a coritract for the use of the vehic[e only. Neiiher customer nor any driver of the vehicle is or rnay be deemed the agent, servant or employee of the dealer far any reason or for any purpose. 7. REPAIRS. Customar wiH not permit any repairs to be made to the vehicle or any liens to be placed upon the vehiCle wiihout the dEaler's consent. Customer�s liabfe tar the cost af any unauthorized repairs. 8. REMOVE KEYS,LOCK DOORS. Customer agrees to remove keys and iack afi doors when leaving the vehicie unattended. 9. NO ASSIGNMENT. Customer cannot and wi11 noi transter or assign this agreement or the vehicle. 1i�. WRIVERlMaflIFICAT10N OF TERMS. This agreement is the entire agreemant between the deaier and custamer. Any changes to this agreemen# musi be in writing and signed by the dealer. �.. _._- __.. .._____ 'y - �..���.�.,. ��� .. _ Luther Westsicle Volkswagen �• Soles Houa: 8:30am•9:OOpm M-Thurs. Tel. (952)377-4100 8:30am-6:OOpm Fri. TF (888)464-5426 8:30am•5:OOpm Sat. Fax(952)374-0675 www.lutherauto.com �^�1Ce Hours: 6:OOam-9:OOpm M-Thurs. b:00om-B:OOpm Fri. B:OOam-A:30pm Sat. 2370 Highway 100 S. parts Hours: b:00om•S:OOpm M-Thurs. St. Louis Park, MN 55416 b:00om-B:OOpm Fri. 8:OOam-4:30pm Sat. PARTS HOURS: MONDAY-THURSDAY 7:OOAM-8:OOPM FRIDAY 7:OOAM-6:OOPM SATURDAY 8:OOAM-4:30PM THANK YOU FOR YOUR BUSINESS! 47435 CASH MICHAEL 05/22/14 PQ CASH '°�. "�. 1 0 367-601-025-G-1Z2 WHEEL 385.00 385.00 385.00 385.00 RESTOCK CHARGE 0.00 T� 28.01 FREIGHT 0.00 413.01 19:47:04 CUSTOMER COPY '`* PRICE QUOTE ** NET677 PAGE MAY 23, 2014 SPG INQUIRY Store 13 SERVC01 566/5090 3350 -------------------------------------------------------------------------------- � MAKE: Volkswagen MODEL YEAR(S) : 2002 MILE: 160492 � � MODEL: Passat 90/10 OPTION(S) : Base PL: 100 � � ENGINE(S) : 2 .8L 6 Cyl TOTAL $ 3411.15 � � --------------------------- VIN: WVWYH63.B02E197544 --------------------------- � I OPERF,TION SUMM�RY INFO CODES CP � � LN JB OPCODE DESCRIPTION PART AVAIL � � * 1. 2 OOVWZZSOF Synthetic Oil & Filter Change - 2 .8L ATQ YM 84.68� � * 2 . 3 45VWZZRENTAL Rental Car Charges - Customer or Service M 1.50 � � * 3 . RSD Rear Suspension Diagnosis - All 116.88 � � * 4. 42111901a REPLACE BOTH REAR TIE RODS SEIZED - 4Mot N 0 705.42 � � * 5. 01VWZZ4WA Align Four V�Theels - 98/05 M 148.45 � � * 6. AIRBGD Air Bag/Restraint 5ystem Diagnosis - Al1 116.88 � � * 7. 37561950 Trans Pan Gasket, r&r - 02/05 N 0 744.24 � � * 8. 40501900 Front Steering Knuckle, r&r (ADD Alignme N 0 1032.01 � i * 9. 40571950 Front Axle Wheel Bearing, r&r (ADD Align Y O 574.20i � PARTS: $ 1291.72 � � LABOR: $ 2000.45 � i S ENVIRONMENTAL DISPOSAL: $ 25.00 � TAX: $ 93 .98 � -------------------------------------------------------------------------------- (E=ENTER) (LINE#) (N=NEXT) (A=ADD) (CO=COMBINE) (X#=EXPAND) (M#=MAP OP) (TAB) LUTHER WEST SIDE VOLKSWAGEN SPG REPAIR ESTIMATE ESTIMATE # R0425046 ESTIMATE DATE: 05/22/2014 VEHICLE: Passat 90/10 VIN: WVWYH63B02E197544 ADVISOR # 716 TRACEY SCHRUPP CUSTOMER # 64043 DANIEL SPRIK ADDRESS: 139 14TH AVE NE (H) 612-385-2382 (g) (EXT) MPLS, MN 55413-1060 CUSTOMER QUOTE OPERATION: OFGA ynt e ic Oi & Fi ter C ange 2. L ATQ 0 0 T�AROR HOURS: 0.40 QTY PART NUMBER PART DESCRIPTION PART PRICE EXT PRICE 1 VW078-115-561-J OIL FILTER 14.58 14.58 70 VWG-052-167-SO ENGINE OIL 0.62 43.40 1 VWN-013-849-3 WASHER 1.78 1.78 MISC CODE MISC DESCRIPTION QUOTE MIN QUOTE MAX PRICE SS S ENVIRONMENTAL DISPOSAL 1.50 25.00 1.87 LABOR $: 18.70 PARTS $: 59.76 GOG $: 0.00 MISC. $: 1.87 T�{ $; 4.3 5 ------------------------ SUBTOTAL $: 84.68 ---------------------------------- --------------------------------------g---_- y OPERATION: RENT Rental Car Char es Customer or Service Contract Pa All T�AROR HOURS: 0.00 MISC CODE MISC DESCRIPTION QUOTE MIN QUOTE MAX PRICE SS S ENVIRONMENTAL DISPOSAL 1.50 25.00 1.50 RC RENTAL CAR-CUST PAY/EXT WARR 0.00 g� RENTAL MISC (GAS, MILEAGE, ETC) 0.00 LABOR $: 0.00 PARTS $: 0.00 GpG $: 0.00 MISC. $: 1.50 Tpx $; 0.0 0 ------------------------ SUBTOTAL $: 1.50 ----------------------- ---------------------------- p � OPERATION: RSD Rear Sus ension Dia osis Al1 LABOR HOURS: 0.85 MISC CODE MISC DESCRIPTION QUOTE MIN QUOTE MAX PRICE SS S ENVIRONMENTAL DISPO5AL 1.50 25.00 10.63 T�AROR $: 106.25 PARTS $: 0.00 GOG $: 0.00 MISC. $: 10.63 Tp,X $; 0.0 0 ------------------------ SUBTOTAL $: 116.88 ----------------------------------------------- 12:24:38 CUSTOMER COPY PAGE 1 OF 4 LUTHER WEST SIDE VOLKSWAGEN SPG REPAIR ESTIMATE ESTIMATE # R0425046 � ESTIMATE DATE: 05/22/2014 VEHICLE: Passat 90/10 VIN: WVWYH63B02E197544 ADVISOR # 716 TRACEY SCHRUPP CUSTOMER # 64043 DANIEL SPRIK ADDRESS: 139 14TH AVE NE (H) 612-385-2382 (B) (EXT) MPLS, MN 55413-1060 CUSTOMER QUOTE OPERATION: 42111901 REPLACE BOTH REAR TIE RODS SEIZED 4Motion 2.SL ATQ 99/05 Both LABOR HOURS: 2.50 QTY PART NUMBER PART DESCRIPTION PART PRICE EXT PRICE 2 VW4B0-501-530-C TIE ROD 116.84 233 .68 2 VWWHT-001-657 WASHER 5.12 10.24 2 VWWHT-001-973 SCREW 24.03 48.06 2 VWN-102-412-01 SCREW 4.08 8.16 4 VWN-906-350-01 NUT 3.20 12.80 MISC CODE MISC DESCRIPTION QUOTE MIN QUOTE MAX PRICE SS S ENVIRONMENTAL DISPOSAL 1.50 25.00 25.00 LABOR $: 344.72 PARTS $: 312.94 GOG $: 0.00 MISC. $: 25.00 TAX $: 22.76 �� SUBTOTAL $: ^ 705.42 --------------------------------------------=�--------------------------------__ ' OPER.ATION: AL4W Align Four Wheels 98/05 T�AROR HOURS: 2.00 MISC CODE MISC DESCRIPTION QUOTE MIN QUOTE MAX PRICE , SS S ENVIRONMENTAL DISPOSAL 1.50 25.00 13 .50 I I LABOR $: 134.95 I PARTS $: 0.00 ' GOG $: 0.00 ' MISC. $: 13 .50 TAX $: 0.00 ------------------------ SUBTOTAL $: 148.45 -------------------------------------------------------------------------------- OPERATION: AIRBGD Air Bag/Restraint System Diagnosis All T�AROR HOURS: 0.85 MISC CODE MISC DESCRIPTION QUOTE MIN QUOTE NIAX PRICE SS S ENVIRONMENTAL DISPOSAL 1.50 25.00 10.63 LABOR $: 106.25 PARTS $: 0.00 GOG $: 0.00 MISC. $: 10.63 TAX $: 0.00 ------------------------ SUBTOTAL $: 116.88 -------------------------------------------------------------------------------- 12:24:38 CUSTOMER COPY PAGE 2 OF 4 LUTHER WEST SIDE VOLKSWAGEN ESTIMATE # R0425046 SPG REPAIR ESTIMATE ESTIMATE DATE: 05/22/2014 VEHICLE: Passat 90/10 VIN: WVWYH63B02E197544 ADVISOR # 716 TRACEY SCHRUPP CUSTOMER # 64043 DANIEL SPRIK ADDRESS: 139 14TH AVE NE (H) 612-385-2382 (B) (EXT) MPLS, MN 55413-1060 CUSTOMER QUOTE OPERATION: 37561950 Trans Pan as et, r&r 0 05 T�AROR HOURS: 3 .80 QTY PART Ni7MBER PART DESCRIPTION PART PRICE EXT PRICE 1 VWO1V-321-371 GASKET 61.66 61.66 1 VWO1V-321-379 WASHER 6.87 6.87 4 VWG-052-162-A2 ATF OIL 19.99 79.96 1 VWO1V-321-377 DRAIN PLUG 17.42 17.42 MISC CODE MISC DESCRIPTION QUOTE MIN QUOTE MAX PRICE SS S ENVIRONMENTAL DISPOSAL 1.50 25.00 25.00 LABOR $: 541.26 PARTS $: 165.91 GOG $: 0.00 MISC. $: 25.00 TAX $: 12.07 ------------------------ SUBTOTAL $: 744.24 -------------------------------------------------------------------------------- OPERATION: 40501900 Front Steering Knuckle, r&r (ADD Alignment) 2.8L AHA/ATQ 98/02 RH T�AROR HOURS: 2.70 QTY PART NUMBER PART DESCRIPTION PART PRICE EXT PRICE 1 VW8D0-407-258-AM HOUSING 415.19 415.19 1 VW4A0-498-625 BEARING 163 .17 163 .17 2 VWN-102-861-02 NUT 1.88 3 .76 2 VW4D0-407-644-A NUT 3 .91 7.82 MISC CODE MISC DESCRIPTION QUOTE MIN QUOTE MAX PRICE SS S ENVIRONMENTAL DISPOSAL 1.50 25.00 25.00 T�AROR $: 374.16 PARTS $: 589.94 GOG $: 0.00 MISC. $: 25.00 TAX $: 42.91 ------------------------ SUBTOTAL $: 1032.01 -------------------------------------------------------------------------------- OPERATION: 40571950 Front Axle Wheel $earing, r&r (ADD Alignment) 2.8L AHA/ATQ 98/05 One T�AROR HOURS: 2.70 QTY PART NUMBER PART DESCRIPTION PART PRICE EXT PRICE 1 VW4A0-498-625 BEARING 163.17 163 .17 MISC CODE MISC DESCRIPTION QUOTE MIN QUOTE MAX PRICE SS S ENVIRONMENTAL DISPOSAL 1.50 25.00 25.00 12:24:38 CUSTOMER COPY PAGE 3 OF 4 LUTHER WEST SIDE VOLKSWAGEN SPG REPAIR ESTIMATE ESTIMATE # R0425046 ESTIMATE DATE: 05/22/2014 VEHICLE: Passat 90/10 VIN: WVWYH63B02E197544 ADVISOR # 716 TRACEY SCHRUPP CUSTOMER # 64043 DANIEL SPRIK ADDRESS: 139 14TH AVE NE (H) 612-385-2382 (g) (EXT) MPLS, MN 55413-1060 CUSTOMER QUOTE T�AROR 374.1 PARTS $s 163 .17 GOG $: 0.00 MISC. $: 25.00 Tp,g $: 11.8 7 ------------------------ SUBTOTAL $: 574.20 -------------------------------------------------------------------------------- TOTAL LABOR $: 2000.45 TOTAL PARTS $: 1291.72 TOTAL GOG $: 0.00 TOTAL MISC. $: 25.00 TOTAL TAX $: 93.98 -------------------------------- ESTIMATE TOTAL $: 3411.15 CUSTOMER SIGNATURE Thank you for allowing Westside Volkswagen to prepare your estimate. ********************THIS IS A PRELIMINARY ESTIMATE*********************** This estimate is based on our inspection or by your request. It does not cover any additional parts or labor which may be required after the components have been disassembled. Occasionally, after the work has begun worn or damaged parts are discovered which are not evident on the first inspection. Because of this the above prices are not guaranteed, and are valid for the actual month of this estimate. Please contact our Service Department at (952)377-4100 to schedule an appointment. ************************************************************************* 12:24:38 CUSTOMER COPY PAGE 4 OF 4 ��j'� � �'� a Get the App Tools for Government Login Sign Up 9�� � � St. Paul, I�N `' '�.`����:, _ � Foilow this Place '-�* • � :i' NOME > ISSUES > POT}10LE � � TDTAL � 1/�`I'G'�� A . . s. • . . . . e • � VOTES ��. M � Pothole - ��kn��ledged *Main r'}�t-�;> ;r�r�Y ��,,:.G.�= 5<r:r1r�'�atTt, !�fii`�l�51�`E�. t15� °� Show on Map E� Photos and Videos a� �AI Notified � Issue ID: 1055613 ft�aoR�R ' �Follow ; Viewed: 54 times An anonymous Neighborhood: Sf. Paul SeeClickFx use� I� Flag Issue C;ib'"iC F�t;i�fS:(i Reported via: rnobile application Reported: on 04-28-2014 NEARBY ISSUES Pothole DESCRIPTION � ;�� t ,,; ,�,��,,,, , �,,��� Horrible and deep pothole. Popped my tire, waiting to see how much in damages. ; ,�,.?; �,::-,; Share � 0 � � � � Pothole �lr�,�t,rt!r±k,�L��z�rr� } x�:::? Seeriic��ix user' NFJ�RBY I SSUES Pothole � . � Etc:(tt7rtry;l t�y 4 ,�IeV r Pothale ' Pothole � Pothole «.. . , � ' Pothole ' Pothole � s�F�,r r :c�y �anaa�Ei �e:r Group of Pothale �, ,.,,,.�, .,,�,<..,,. _ 5 C�MME�JTS You may also like this _ _ _ � Potholes piggm(Registered User) ` • 311 Ramsey Street Saint Paul, h � I reported that a month or so ago. Not surprised about your tire. Diggitt McL Q4-28-2014 Fiac7 ,e,;•;,�_ wi.c:a� Public Works Admin 3(Verified Officiap Thank you. Your complaint has been sent to Public Works Street Maintenance for re�iew. 04-29-2Q14 Flag � ��I ' F � :� � 3 =� j i Algus(Registered User) Beware. aa-29-2o�a �ia9 danielvh(Registered Userj ` i hit this yesterday with my car, it popped both the front AND Rear tires, and also damaged my wheels and suspenstion. 04-30-2014 Flag :: danietvh(Registered User) `' this is right in front of the apartment building at 510 Grand. 04-30-201� Flag NE1N COMMEfVf ��'Yi9�h:��n�r�;r;f;rat,,. : I want to... ' ' �j* Leave this issue Acknowledged ' Attach: m Phata �Video � • • • • � i s • � - , . . Twitter ' Facebook Blog Help ' Contact About Us ' Jabs Language:English� � _ `. Z . . ;C:<<1.� ,.Ir, ��i <;�t r ,�:;�"�°;.�. �.;rrn. nf�',, ��j" � ��" � Get the App Tools for Government Login Sign Up 'irjR �'1� S#. Pa u I,��M N l��,����:_, � � _ _ �,������������ ;�la � Foliow this Place ,� =g+ • o :•- HOA•� > ISSUES > POTHOLE �—e_ 2 TOTAL . � ..: . : .Y i • - �p�s "�` V�7E�: Pothole - A�knornrledg�d * Ma;,, 5.x7-5'F�?We��C3r<�r����fFr?ctF S�ir�t ('�rrf, rV17ll:5�7C��'. tl�>l! � Show on Map ' � Photos and Videos � ,�I Notified $ �� issue ID: 1002955 R�PO�.��� , ' �Follow ���'�""' � Viewed: 30 times An anonymous `"� �" »�;° • SeeClickFx user '' �~ Flag (ssue � ` Neighborhood: ,. St. Paul ,' ,��>�:,�� `' � ' Reported via: mobile application NEARBY ISSUES Reported: on 03-27-2014 Pothole f��ai,rl�re k t Art��rir y x;'..�. j (ii:�i-ix!s��;` ' '' Pothole � �Zwc��;rl���`t�v iar�<tr�s��.y.�::=s '�� ' :,s�,C:liCk�ix u:,�,r Pothole . . . . . i� k';f'.',)ti(}..�C? ' {k">t'yf}:'1' DESCRIPTION "'' No description provided. Pothole Share ' � 0 '��i�i � � � Kf t r �:�, an � c;u� . .... . . .. . ��� .. .. ...... .. � � ,xi�r{,Ii�.Kf��k 15�.0 NEARBY ISSUES Potho�e �r ,.,r,:��� . , t� . _ You may also like this ' Pothole Pothole Pothole - ,�� Pothole . "'` 501-551 Grand A�enue Saint Pai. Pothole 1 COMMENT � �y�W s ���i��Public Works Admin 1 (Verified Officialj Thank you. Your complaint has been sent to Public Works Street Maintenance for repairs. 03-28-2014 Fiag �� . � � �� �` NEW COMMENT i�r'rit�r� r,aC��t�=�;E�3-�t... �� /. ': I want to... ` `�#� Leave this issue Acknowledged Attach: � Photo �Video � i � ! ` ! i i ' � ` ` • • Twitter ' Facebaok Blog ' Help ' Contact About Us Jobs Language:English� :?�'`�� �i+'*� t*�--f?C.I€C;kJ�.X.IY`E:.t�II �±"t°i CE ,��v; _..- CG:7'(Yl7E)I�,"_ �roup of Pothole - St. Paul, MN - Issue #992286 - SeeClickFix Page 1 of 3 Get the App Tools for Government Login Sign Up S�. Pa u I, M N �changeJ i Fol►ow this Place Report an Issue _____________._____...__� � � Issues Answers Neighbors Watch Areas HOME > ISSUES > GROUP OF POTHOLE Acknowledged by: St. Paul, MN (Saint Paul Connect) Group of Pothole�Acknowledged 553-555 Grand Avenue Saint Paul, Minnesota • Show on Map Issue ID:992286 REPORTER Viewed:11 times Diggitt Neighborhood:St. Paul Civic Points: 175 Reported:on 03-19-2014 DESCRIPTION At the bend of Grand Avenue,just about the point where Oakland enters, is a cluster of deep potholes. Westbound cars have no choice but to come almost to a halt and creep among the potholes. IYs a big hassle for the buses on the route as well. Share o 0 0 NEARBYISSUES Potho►e Pothofe Pothole Pothole �ra • . � 1 COMMENT ACKNOWLEDGED Pubiic Works Admin 1 Nerified Official} Your complaint has been sent to Public Works Street Maintenance division for review. 03-20-2014 Flag NEW COMMENT Write a comment... I want to... C: Leave this issue Acknowledged http://seeclickfix.com/issues/992286-group-of-pothole 8/22/2014 Group of Pothole - St. Paul, MN - Issue #992286 - SeeClickFix Page 2 of 3 Attach: Photo Video Comment � Vote! 4 TOTAL VOTES Main Photos and Videos $ Notified Follow Flag Issue NEARBY ISSUES Pothole Reported by An anonymous SeeClickFix user Pothole Reported by An anonymous SeeClickFix user Pothole � Reported by Ashley � � Pothole Reported by An anonymous SeeClickFix user Pothole Reported by James Buscher http://seeclickfix.com/issues/992286-group-of-pothole 8/22/2014 Group of Pothole - St. Paul, MN - Issue #992286 - SeeClickFix Page 3 of 3 MC��I�� �1��5 fC�t" CI�I�S Custom cir�r apps cc+nnect and engsge c%tizens v+,rh+il�streamlirr�ng warflow for city officials • Cus�om mr�bile apps and web widgets • Autamat�t routin�and assignment � D�taile�i analytscs • City iCnowiedge B�se � Solutions For Tools for Mobile Apps Government Citizens iPhone Android Windows Phone Media Partners Community Groups BlackBerry Report Toll-free: +1 800-209-4963 Developers BlackBerry Windows Phone Android iPhone Twitter Facebook Blog Help Contact About Us Jobs Lang�age:Engiish • OO 2008-2014 SeeClickFix, Inc. All rights reserved. -Terms of U� http://seeclickfix.com/issues/992286-group-of-pothole 8/22/2014 Pothole - St. Paul, MN - Issue #1060097 - SeeClickFix Page 1 of 3 Get the App Tools for Government Login Sign Up S�. Pa u I, M N �change] ; Follow this Place ! Report an Issue Issues Answers Neighbors Watch Areas HOME > ISSUES > POTHOLE Acknowledged by: St. Paul, MN (Saint Paul Connect) Pothole�Acknowledged � 553-555 Grand Avenue Saint Paul, Minnesota • Show on Map Issue ID:1060097 REPORTER Viewed:38 times Gordon Ueland(Guest) Neighborhood:St. Paul Reported:on 2014-05-02 Tagged:pothole, bridge DESCRIPTION Several potholes on Grand Ave from Oakland to West 7th Street. One large one on South end of Grand bridge over 35 E. Share o 0 0 NEARBYISSUES Pothole Pothole Pothole Pothole � . � � 3 COMMENTS Diggitt(Registered User) There are some appalling ones befinreen Dale and Ramsey Hill. In the five hundred feet downhill from Lincoln, some of them could blow your tire. And there's a bad one just over the bridge across 35, where the concrete of the bridge turns back into asphalt. I don't mean to imply the mess where Oakland joins Grand should be ignored--it certainly slows people down to about 5 mph if they know iYs there. Thanks for reporting this. 2014-05-02 Flag Diggitt(Registered User) For this strip of road we need severat markers! 2014-p5-02 Flag http://seeclickfix.com/issues/1060097-pothole 8/22/2014 Pothole - St. Paul, MN - Issue #1060097 - SeeClickFix Page 2 of 3 ACKNOWLEDGED Public Works Admin 3(Verified Official) Thank you. Your complaint has been sent to Public Works Street Maintenance division for review. ' 2014-05-02� Flag NEW COMMENT Write a camment... ' I want to... ' #: Leave this issue Acknowledged . . . .... Attach: Photo Videa �Q�"'�'�r'� , Vote! 4 TOTAL VOTES Main Photos and Videos 8 Natified Follow Flag issue NEARBY ISSUES Pothole Reported by An anonymous SeeClickFix user Pothole Reported by An anonymous SeeClickFix user Pothole Reported by Ashley � � � PothoEe Reported by An anonymous SeeClickFix user PothoEe Reported by James Buscher http://seeclickfix.com/issues/1060097-pothole 8/22/2014 Pothole - St. Paul, MN - Issue #1060097 - SeeClickFix Page 3 of 3 Requ�st Ma�age���nt Tac�1s Tum c�ampiaints int�a productive rr�oricflc�w with f��+sced�SeeClaek�ix tcr�3s and third parr�snte�rata�an � Cu�tcr�n mabil'e a�aps and web wi�gets � Aut�m�tic routing�nd assignment • Detail�d analytics • City�Cnomv�edge Bas� � � Sofutions For Tools for Mobile Apps Government Citizens iPhone Android Windows Phone Media Partners Community Groups BlackBerry Report Toll-free: +1 800-209-4963 Developers BlackBerry Windows Phone Android iPhone Twitter Facebook Blog Heip Cantact Abaut Us Jobs �anguage:Engiish r O 2008-2014 SeeClickFix, inc. All rights reserved. -Terms af U� http://seeclickfix.com/issues/1060097-pothole 8/22/2014 Pothole - St. Paul, MN - Issue #1061594 - SeeClickFix Page 1 of 3 Get the App Tools for Government Login Sign Up �►/�A� [change� �---- ____ S�. Paul� Ir11� Followthis Place ; Repork an Issue ; issues Answers Neighbors Watch Areas HOME > ISSUES > POTHOLE Acknowledged by: St. Paul, MN (Saint Paul Connect) Pothole�Acknawledged 501-551 Grand Avenue Saint Paul, Minnesota � Show on Map Issue ID:1061594 RePORTER Viewed:14 times mrichmond(Guest) Neighborhood:St. Paul Reported:on 05-02-2014 DESCRIPTION several deep potholes on side of road going towards downtown Share 0 0 0 . NEARBY ISSUES Pothole Pothale Pothole Pothole �� • „ � 1 COMMENT ACKNOWLEDGER Public WorkS Admin 3(Verified Officiai} Thank you. Your complaint has been sent to Public Works Street Maintenance division for review. 05-d2-201 A Flag NEW COMMENT _ _ _ _ _ 'Write a comment... I want to... C• Leave this issue Acknowledged ' http://seeclickfix.com/issues/1061594-pothole 8/22/2014 Pothole - St. Paul, MN - Issue #1061594 - SeeClickFix Page 2 of 3 � Attach: Photo Videa Vate! Comment � 3 TOTAL VOTES Main Photos and Videos $ Notified Follow Flag Issue NEARBYISSUES ' Pothole Reported by An anonymous SeeClickFix user Pothale Reported by An anonymous SeeClickFix user Pothole � Reported by Ashley i � �. Pothole Reported by An anonymous SeeClickFix user ' Pothole ? Reported by James Buscher http://seeclickfix.com/issues/1061594-pothole 8/22/2014 Pothole - St. Paul, MN - Issue #1061594 - SeeClickFix Page 3 of 3 ��q!u��t M��a����r�t T�QI� Tum cc�mpl�ints ir�tc��Srcre3�tctir��wcsrkflcr�v wit�a hosted 5ee�[�c�;Fix to�t�arad thir�i parry integr�ttan • Cust�sm mflbile apps and web v�ridg�ts • A�tc►mak�e rautin��nd assignm�nt • Det��led analytics • Cit�Know3edge Base Solutions For Tools for Mobile Apps Government Citizens iPhone Android Windows Phone Media Partners Community Groups BlackBerry Report Toll-free: +1 800-209-4963 Developers BlackBerry Windows Phone Android iPhone Twitter Faceboak Blog Help Contact Abaut Us Jobs Language:Engiish � O 2008-2014 SeeClickFix, Inc. All rights reserved. -Terms of U� http://seeclickfix.com/issues/1061594-pothole 8/22/2014 : . � _ ��6 � � _ . : �� �� ��.. .. � . .��; �H. �- . �� .. .�.. ': �f 4���. ,, ;F�.. . i .,�. ... 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' � �� � §.� ��, •� "��,���f e?�. r.�'�. � U � � � � � � � �• .; A �j�� m�°°a....� ., � � :. � � �` �e�. �a� � ' t� � .;,� � .., �� � ;�. � ` a �;� � s �� �� r;� �. `' ��� �� ;� � . . � �a � �.���,��a ,� a?�;,�� . � � r � x t�-# "m :� ,#,s,u. - � ? , sr . � r�. � ��' ,��'.+�' .�° ;�;:. '�.�F �, a'�' �v��� ��, �, ��. ",p�. �, �b �„� � �`� �'�t � �h �� � ������� ����� � .�; �, � � `� � , � � 3 ��� a �� � , �� � � � �S<� �: , . � �� ��' � , `r; � �• , Doc No A10089655 Certified, filed and/or recorded on Jun 18, 2014 12:00 PM Office of the County Recorder Hennepin County, Minnesota Martin McMormick, County Recorder Mark Chapin, County Auditor and Treasurer Deputy 52 Pkg ID 1122227M Doc Name: Change of Name Document Recording Fee $46.00 Document Tofa/ $46.00 P4D{s) 14-029-24-22-0006 15-029-24-14-0080 , This cover sheet is now a permanent part of the recorded document. FILEQ State of Minnesota 13 i�Gt� ?_5 p F� S� 2� District Court County: Hennepin Judicial District: Fourth �,�T _c�r�u7 rCourt File Number: 27-CV-13-20455 ���i{;`hri`rA,^�F���'� ;i u�r j n R Case Type: Name Change In the Matter of the Application of: Daniel Jax S� rirst Middle Last Order Granting Name Change For a change of name to: �Mlnn. Stat. � 259.10� Daniel Jay Van Hofwegen First Middle Last The above entitled matter came on for hearing before the undersigned Judge on November 26,2013 upon the Application for a Name Change. Upon the testimony and itles,THE COURT FINDS the following: l. The application is made in good faith without intent to defraud or mislead. 2. The applicant(s)has/have lived in the State of Minnesota for at least six months preceding the filing of the application,and now live at: 139 14`h Ave NE Minneapolis MN 55413 _ in Hennepin County. 3. Name of applicant and date of birth: Daniel Ja�Sprik 9/2/1982 4. Name of spouse and date of birth: This application ❑ does X does not include spouse. 5. Name(s)of minor children and date(s) of birth: ❑ This application does not include minor children listed above. ❑ This application includes the following minor children listed above: 6. This anplicant requests: X To have his/her name changed to Daniel Jay Van Hofwegen �To have the name of his/her spause changed to ❑ To have the name(s)of his/her child(ren)changed to 7. The applicant(and included spouse or child(ren)) X Has not been convicted of a felony in any state. ❑ Has been convicted of a felony as follows: AND � Proper notice has been given to the prosecuting authority and Minnesota Attorney General AND ❑No objection has been filed. 8. Legal description of lands in the State of Minnesota upon which the following have a claim, interest,or lien: (Provide the legal description and attach additional pages if necessary.) X Applicant Rock Countv—Lot 6 Block 1 Halverson's Addn Lot 6-8 Block 1 and See Attached ❑Spouse ❑ Child(ren) NAM107 State ENG Rev 8/05 www.mncourts.qov/forms Page 1 of 2 9. Other: _ -- The appiication is granted and TT IS ORDERF.D that: X The legal name of the Applicant shall be Daniel Jav Van Hofwe�en A(I persoizs havin� a c►-iminal histor� who have been 5ranted a name change by t.his court have a dut,y to report that name cliange to the t3ureau of Criminal Apprehension within ten (]0)days of this order. ❑ Other � � ,� �l..t:k /��� ;1 ;`" ;. Dated: November 2G. 2�13 �� /�{ �� i l?��% �'. �ll��V� Ju�dge or i�isu-ici Coun. DUTY TO REP012T NAMG CHANGE IVliitn. Stat. §259.1 lB ff you t�ave a criminal l�istoiy and have changed your name,you have a duty to report your i�ame change to tlie Bureau of Criminal Apprehension located �t 1430 East Maryland Avenu�, St Paul, MN 55106, (651.)793-2400, �vithin ten (l0) days of this order. f�ailure to do so is a�ross nlisdemeanor punishable by up to one{I)year in prison and/or a tine of$3000. STATE OF MINNESt�T�C�IMTY OF� 1 t�ereby ceRly , b b�a true and cae�ecct coPY of the ori�l on fN98nd dt+eoo�d M my c�boe. NAM107 State ENG Rev 8/05 www.mncourts.qov/forms Page 2 of 2 �: ___a .. - . `�_ , . . ����•.,�.'� Y\ . . . � . . . . . . � � � � '/ . . � � _ pa� . Z�(- �L _ o00 � 37-M TRUS7'EE'S DEED - � By t.ar;m„u.) . DEED TAX DUE HERF.ON: �314.50: • Date: luly 15 20l 1 - FOR VALUABLE CONSIDERAIION,Gmeory J.Hcgi and Doneld I&o Rich�ns Tnutee(s)of the Agncs Veronica Richler itevocable Trust uada Agceement dated t'rocemuer i9,ZW3 vransor(s�,heret�ccavcy(sJ to,*** . Gr:.a•��:.zce] property in H�nncpin Connry,blinnesoG,d�scdbed as followa: +t** Daniel J. Spr ik 'I�South Half(3 44�of Lot Ei�t(8),Bladc Faat�eea(t4),Baltinrsn'a sa�td l�ddition ta the 'fown of$t Mtho�y,Hemnepin CowYty,Mwnesots. � together with ell heceditamenLt and appuftemnees belonging thusto. . Check bmt if a�plicable: 3'he SeYcr certifies dint the eeller does not lmow of nny welta on tha descn'bed real pnope*cY w ❑A we11 disclosiue coctificate accomPani�e th'"document CI I em familiar with the proPerty dcacribcd in this instiumcnt aad l.certify thet the stntus ead aumbcr of wells on the dcscnbed�a1 propertY have aot cheagcd aince the lut previously filed weU disclowit certificata. 7RUSTEE(S / ory 7. egi �.t-- Donald I.eo RichLar t�uvc Do«I Ta�Siaaip°ac ' STATE QF M4naaota � COUNTY OF Hemepin �� ! ) Tho foregoing was aclmowledged before me on July LS,2011 by Gre ory J.Hegi a�Donald I,eo Richter ae Tn�atee(e)of �6e pgnes Vtconfaa Richter Revocsble'i'rust nndcr Agroement dstcd bcr 1 00 Ornatora. NOTfX1ALST O[YGLIaOT�[ti1LHOR4tlU AiVRiOi A YNmtCOt OFFlawL � � . �� C A R 0 L A M C D 0 NA L D T.:Swantlw fo�ehe r��p�opcey dna;ed In�hb k�saumm�.�w�b���t� ��. .j mclude o�me and�of Ondm): �X[�� �'� NOT�RY 1UYLIG•qINME50T� � 1 ` �I� 4t Cni.�n.E.It•s��en.7i,ta�7 �Q`'eS 1_O 1 5 P("!'� fq � . . na5�ur.�rrw.�wnftm�rM��.ixo�noussl 'Dm�id2nd5trmtNortfieaal �J� I��h ►5tur.N� � . Seew�rt Title of Min+ewM,[ne. �Minoapoli��tA�f 5541 B rnPi51�n a� �-sY�3� 1700 W.BZrd 6trW� � � . su��too REGIS TTRE LLC � �� ✓ Blowni�econ,Minnaoh 35431 ���NTM RO� � � MAPl.ElNG10D MN 55 � 5 _�� n, . -�.... . _ • � � ,� _ ' �, . � - �, � �. . �� 'f '' �� 'C�C-k - . T't�is docume�twas.drafted by: Q�� Continental R'EU Services lnc. � �� ~''��� �� ~��� 7.777 8onhomFne Aven�e Swiie 1100 � `St,Louis,MO 63105 ' ' S�PECIA�. WARRANTY DEEi� Q� G� Deed Ta�Due:$. �y This.Deed is made and entered into this�.day of�,�(��a2009 by and , between ' J.P.Morgan iviortgage F�cquisit;on Cort,. of the County of fJ P�'1�� , State of ����-S � hereinafter collectively�eferred to as"Granto�',and ' Daniel J:$prik � of the Couniy of ,State of hereinafter referred to as°Grantee".The mailing address of the Grantee is WITNESSETH,fhat the Grantors,for and_in consideration ot the sum of Ten Ooilars($10:bOj and qther valuable considerations paid to the G�antor,the�eceipt o(which is-hereby acknowledged,does by these presents GRANT,BARGAIN ANp SELL,CONVEY AND CONFIRM unto the Gra�tee;the lottowing described lots,trects or parcets oi fand lying,being and situated in the County of Hennepin and State of M(nnesota to-wit: � 7hat part of the following described parcel lying NoKheast of a li�e commencing on the North line of t4th Avenue Northeast at a ppint 29.feet Wesi of the intersection of the Nortti line of 141h Avenue and th�East line,of Lot 19, Block 2,Traders Addi#ion to the Town ot SaiM Anthony and terminating on the North line of Loi 19 at a point 40 feet V'lest af,ha�Northeastcomer o`saic!Lot�?;a!!that�a.^.�f�ot�9,81e�k 2.Trader's Addition to the Town of Saint Anthony, known as follows,to-wit: Commencing at a point , - on the IVorth line of 14th Avenue Northeast as exte�ded where it intersects East line of said Lot 19;thenes�lorth to.NoRheast comer of said Lot;thence West along North line - of said l.ot,80 fset more or less.to the mid-point of the NoRh line nf Lot 19:thence Southe�iy to a poiFlt on the North line of said Avenue which is distant 56 feet Wesl from � a point of beginning;thenoe East along 1he NoRh line of said Avenue to place of --beglnning,Hennepin Couni'y. Minnesota. Subject to easements,condlUons,restriciions and limitations ot record. . The Tlw Ckottp,tr�c, ' 11680'fheatts p�ly� Suit�210 ChempHn.�MlJ 5531A G q/��3l96S