10-670Council File # ��—� � Q
Green Sheet # 3 I l3 5�(
RESOLUTION
Presented by
PAUL, MINNESOTA �
� ,
1 Be it resolved that upon proper execution and delivery of a release in full to the City of Saint Paul, the proper City ofFicials are
2 hereby authorized and directed to pay from the City of Saint Paul Public Works Department Tort Liability Fund, GL225-42310-
3 0511, to Farmers Insurancz Company as subrogee of Cindy M. Jandro and Timothy Linder, the sum of eight thousand two
4 hundred ten dotlars and eighty four ceuts ($8,21Q.84) in fu1l and final settlement of alt ctaims relating to a Property Damage
5 claim as a result of a vehicle accident on or about tl�e 24`� day of December, 2009, at or neaz the intersecrion of Randolph and
6 Shepherd Roads in Saint Paul, MN.
Yeas Nays Absent
Bostrom ;/
Carter �/
Harris �
Helgen �
Lanhy �/
Stark
Thune ,/
Adopted by Council: Date ���f��
Adoption Certified by Council Secretary
By: '
Approved pe Date � ,,� �v
By:
Requeste b Dep itm t of
By:
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,�� Green Sheet Green Sheet Green Sheet Green Sheet Green Sheet Green Sheet �
� DepartmentlOffce/Cauncil: � Date Initiatetl: j
; HU-HumanResources ', ZgMAY2010 ; Green Sheet NO: 3113576
Contact Person & Phone:
Sandra Bodensteiner
6512668887
Must Be on Council 1\qenda by (Date):
Doc.Type:RESOLUTION W/$
TRANSACTION
E-Document Required: Y
Document Contact: Sandra Bodenstein
ContactPhone: 6512668887
�
Assign
Number
For
Routing
Order
Total # of Signature Pages 1(Clip All Locations for Signature)
Action Requested:
�
Approval of settlement of property damage claim against the City of Saint Paul's Public Works Department by Farmers Insurance
Company.
�� Recommendations: Approve (A) or Re�ect (R):
� Planning Commission
CIB Committee
Civii Service Commission
Personal5ervice Contracts Must Answer;he Foilowing 4uestions:
1. Has this person/firm ever worked under a contract for this department?
Yes No
2. Has this person/firm ever been a city employee�
Yes No
3. Does this personlflcm possess a skilt not normally possessed by any
current city employee?
Yes No
6cplain all yes answers on separate sheet and attach to green sheet.
Inil tiating problem, Issues, Opportunity (Who, What, When, Where, Why):
� A City of Saint Paul Public Works snow plows entered a intecsection on a red light and was involved in a collision with another
! vehicle. This resolution authorizes settlement of the outstanding property damage claim to the vehicle being presented by Fanners
', Insurance on behalf of their insured.
AdvantageslfApproved:
An outstanding claim against the City will be resolved.
i Disadvantages If Approved:
I None.
GosUKevenue Sudgeted: Y
�isadvanWges lf Not Approved:
An outstanding claim against the City would need to be litigated in order to be resolved and additional costs would be incucred.
ToWI Amount of $$ 210.54
Transaction:
Funding Source: GL225
Activity Number.
I I
•
n �.
Financial Information: public Works Tort Liabi]iTy account
(Explain)
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May 28, 2010 1124 AM Page 1
ID°�o�
� �Y 1 � 2010
Property Damage Release
Fiie Number C-010109 � - �r�
For the sole consideration of eight thousand two hundred ten do4tars and
eighty four cents ($8,210.84), the receipt and su�ciency whereof is hereby
acknowledged, the undersigned hereby releases and forever discharges the City of
Saint Paul, the Saint Paul Public Works Department, Street Division, their heirs,
executors, administrators, agents, and assigns, and ali other persons, firms or
corporations liable, or who might be liabis, none of whom admit any liability, from any
and all claims, demands, damages, actions, causes of action or suits of any kind ar
nature whatsoever, to property which has resuNed, ar may develop in the future from an
incident which occurred on or about the 24 day of Decernber, 20Q9, at or near, the
intersection of Randotph and Shepard Roads, Saint Paul, MN.
The undersigned hereby declares that the terms of this settlement are fully
understood and voluntarily accepted for the purpose of making a full and final
compromise adjustment and settlement of any and all claims, disputed or otherv✓ise, on
account of the property damage mentioned above.
f hereby s#ate that I have read this release, know the cantents thereof, and have
signed the same, relying on my own judgment and on no representations of others, and
of my own free wil! ar�d accord this .��, day of �_�_ ._, 24 !0 .
/1 �
the
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Signature of Auth ' zed
Representative of Farmers Insurance
Company as subrogee of Cindy M.
Jandro and Timothy Linder under
claim number US9-SUB-1015242418-1
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B fiQn V�CSlC;S✓12
Witness Printed Name af Per n Signing Above
36- d66/sis
Tax Idsntification Number
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Noiary Pe i cNSiate of f I��nois
hRy Commission Expires Nov. 25, pp��
F�, YY'9 I Request for Taxpayer I Give form to the
�'°"O°°�r � ldentification Number and Gertiftcation { reQ�ester. Do not
�i,�m.r�em.y � send to ihe IRS.
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❑ limkatl fiabiliry comPaM. Enter the tax ctssvfrcabm li1_tl's�aBmdetl artUry. Cxorporation. F=6�4reF+hiP1 �.""" Q p�
❑ OMmprohcWttMrs�►
Atltlresa �wmber, atreat, enE ept, w sWCa no.) Raquestafs name arid etld�¢ss toptiorial)
�ty. 5I8tq
List axount numba(s� hare
Enter your llN in the epproprtate bax. The TiN providetl must match the name given on llna 5 to avo�d Socsat n°°"'�' rn"^b°'
backup wlthholtAng. Fw Indlvitluels, thfs is your social security number (SSN�. However, for a resldeM
ellen, sote proprietor, or Nsregerded entlty, sea tlie Pert I Instructlons on page 3. For other entMes, It is
your employer ldendflce8an number (EINj. I[ you tlo not have e num6er, see How to get a 71N on pege 3. a�
Note. If the aCCOUnt is fn more then me name, see the chert on page 4 for gulddl�es on whose Employnr ldentlfimtlon wmbar
numbertoe�rter. ' ��, ; 0266!$"/�"
Undar peneftles of per�ury, I ceN�y that
7. The rwmber shown on this fortn !s my correct texpayar ldentification number (m I sm wa1Wg for a number ta 6e fssved to me), and
2. I em not subJ�t to beckup wRhhold"tng beceuse: (� I em exampt hnm backup withhaltling, or (bJ I have not heen noWied by tha Intemel
Revenue Service QRS) thet I em SubJeci ta backup wlthholding es a result oi a 1811Ure to report atl iMerest or diddentls, or (c) the IRS hfls
noUfled me Mat I am no longer subject to �acluip wtthholding, and
3. I em e U.S. dthen or other U.S. person [definad balow).
CertNicatSon irtsWCtions You must cross o�t Itesn 2 above EE you have been'wtified by the IRS that you aze cu�renM/ sub]at to 4aclap
wRhh�ltling because you have fslletl to report all Interest and dNfdentls on your tex reNm. For refll estate transacNons, Item 2 does not ¢pply.
For mortgege Interest paitl, ecqulsttion or ahanConment o( secured properry, ranceliatian of tlebt, contribu[ions to en intllvitlual�retlrement
artangemen( QRy, end germrally, peym ts other than interest entl tlrvldends, you ere not requiretl [a sign ihe Car[iflcatlon, Gut yau must
provide your correct T1N. See the insm�'rons an page 4.
°�y�� I Sigrunaeaf �/� ,
Here � ❑s. oersoo ►%
General Instructions
Section references are to the Intemal Reven�e Code unless
othenvise noted.
Purpose of Form
A pefson who is raqu�red to file an infortnation retum wcth the
IRS must obteln your correct ta�ayer ldentiflcation number (TIM
to report, ior erample, tncome paid to yov, real escate
transactlons, mortgage interest you paid, acquisition w
abantlonment W sawred property, cancella[ion of debt, or
cantributions you mede to an IRA
Use Form W-9 only if you are a U.S. person (ncluding a
resident aiienJ, tv provide yaur correct 71N to ihe person .
requesting It (the requeste� and, when applicable, to:
1. Certify that the 11N you are giving is correc[ (or you are
waEting for a nurttber to be IssueUJ,
2. CeNfy that }rou are not subject to backup withholding, or
3. Clalm ezemptlon from hackup withholding_"rf you are a U.S.
ezemPt payee. N applicable, you are atso certttying that 25 a
U.S. person, your elfocabla share ot any parviership income from
a U.S. trade or 6uslness is rrot subject to tt+e wi[hhoiding tax on
Eoreign partners' share of efiectivelyconnected income. -
Nota. 1f a requester gives you z tortn other than Fortn W-9 to
request your TIN, you must use the requestets form jf It is
suSstanUaily sirnllar to [hls Fottn W�3Y .. ��Ij
Definition ot a U.S. pe�son. For federal tax purposes, you ara
wnsidered e U.S. person tt yau aze:
• M Indivldual who is a U.S. cltlzen or U.S. resldent alien,
• A partnership, wrporation, comparty, or associatlo� created or
organ¢ed in the Untted States or urWer the laws of the United
States,
• An estats (other than a toretgn e5tece), or
• A domesUc tivst (as da4tred in Regulati�ns section
301.7701-7J.
Spec3al rules for parfiershlps. Partnerships thet conduc[ a
trada or business in the UnRed Siaces are geneia7ry required to
pay a withholding tax on arry torelgn partners' share of income
{rom such tsuslness. EuRher, in ceRain cases where a Form W-9
has not been received, a partnership is required to presurtre that
a partner is a foreign person, and pay Ne wiihholding tax.
Therefore, if you are a U.S. person that is a partner in a
partnership contlucting.a hade or busirw..ss in the United States,
provide Fortn W-9 to the partn�ship to c.ta5llsh your US.
status aM avold withhol�ng on your share of partnership
income.
The person who gives Form WA to ihe partnership for
purposes of estsb(�sFting its U.S. siatus and avoiding w+thhoiding
on Rs allop6la share of net income fiom the partnership
mntluctl� a trade or busl�ss In khe llnded States 5 in the
following cases: _
• The U.S. owner of a disregarded entity and not ths entity,
Cat No. 10237X '
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