Mills, Aaron (1)NOTICE OF CIAIM FORM totheOtyof SaintPaul, Minnesota
Minnesoto stote stotute 466.as stutes thot ,...every person...who claims damoges from any municipality..'shall couse to be presented to the governing body af the
fiunicipatity within rg0 days after the alleged loss or rnJury is discavered o notice stoting the tlne, place, snd circumstances thereof' and the amaunt of compensation
or other reliel demonded."
please complete this form in its entirety by clearly typing or printing your answers to each quEstion. tf you have addttional documentation, l'ou may add those
documentr to your submission. you wlll not be conta*ed by telephone unless clarification is needed. The clalm proces for irwe$tiEations can take upwards of four (4)
weeks. This form must be signed, dated with all appllcable sectionr completed. submission this completed form to the saint Paul citv clerk's office bv email
{cityclerk@ci.stpaul.mn.us}, fax (6s1-a66.g574} or mail addressed to *saint Paul city clerh :5 west KelloSS Blvd.,5uite31o Salnt Paul, MN 55102"'
grA Last Name:fli rrJClaimant: First Name:
please tndicate Your Pronouns: tr ShelHer/H ers, d+efiim/His, tr They/ Them/theirs
Company or Business Name:
lsthisclaimbeingmadebyanlnsuranceCompany?vrsi@rves,whatisyourClaim/FileNumber?
ls this claim being made by an Attorney? YES
lf yes, provide Your lnsured's/ Client's Name:
Street Address:
City:tt,(') Il" rxt^t State f,\Zip Code:5 ")-it L
Daytime/Work Phoner (e)- 35 t, -{-rc L
Date of lncident or Date Discovered {Must Complete)l
please state, in detail, what happened that prompted you to file a Notice of claim
Cell Phone;Grl->rb- "l'{at
Time;
'] lor: f ;!.
/t 1-
L AiL*r all
1-(a_
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Please state why or how you feel the City of Saint Paul is responsible for your
*r54 fd,.i d" lg
Please check the reason that most closely describes the reason for your submitting a claim'Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submitted become the Property of
the City of Saint Paul and shall not be returned.
fr Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid'
I
E! Automobile damage from a street defect or potholet please provide two estimates for repairs or actual billthat has been paid'
E Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket {if available}, receipt
from lmpound Lot, and two estimates for repairs or actual billthat has been paid'
E snow Emergency: please provide copy of towing ticket (if available), receipt from lmpound Lot, and tws estimates for repairs or
actual bill that has been Paid'
fl property damage: please provide two estimates for repairs or actual bill that has been paid.
E you were injured during a motor vehicle accident; please provide police report number, details about injury'
I you were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury'
Continue to page 2 of Notice of Clalm Form. Failure to complete and return both pages will result in delays'
&:-
Revised Morch 2A23
This section must be comnleted for all claims.
ls there a police report for this incident? YES (G
lf yes, please provide the police report case number:
lf yes, what law enforcement agency responded?
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:Cru r f,r^r-- .Y- (,*1t^-c. g-
What would you like to8.:n 6*1.^.*on*
see happen to resolve this claim to your satisfaction?
.aF +t* {o{gP feT {a*. 1a e-^.{-.L-cJ{
Were there witnesses to this incident? Please provide names and contact phone numbers:V*/- A,^^,r--'.Jo- Alrr, 6tL- Llt" - t(Lb
Fgr oropertv damage claims. includine vehicle accidents.
Your vehicle's information: Year: ?-o t "t Make:f- ",f J
License Plate fi Fr rt^- 1*?-i
Registered owner of vehicle:4.,.^o- A- r {t/
Model:| ^).0\Color: {s; "'' t
State vehicle is registered in:hN
Driver:d+"-.,*w,i tll
i're"{L **f t^:\;* +f""e*Area(sldamaged ,'.'"k ni L*
lfaCityvehiclewasinvolved,LicensePlate#:Color:
Was there City insignia on the vehicle? YES / NO Driver's Name: _
Other property damaged:
For iniury claims of any tvpe.
What part of your body was injured?
Didyougototheemergencyroomorurgentcare?YES/NoWhere?
Was medical treatment received? YES / NO Where? _
First day of medical treatment?
-
Are you still receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s):
How much time have you missed from work? - --
lf you are submitting other documents, please state what you are attaching and how many pages:{lr <- ft- *t lrre**-ea 4 Q.o'-: q*i
By signing thls form, you agree that all information provided is true and correct to the best of your knowledge.
Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes.
Name of Person completing form:A o-' * d{.t'r l}
Signature of Person submitting this form:
-1
//a.^* /ltnl'L
Relationship of person signing to Party making the claim:
Date document is being signed:Lllrt / i-1
5 al€
Revised March 202i
2s1
PARKWAY AUTOCARE
1581 FORD PARKWAY
ST PAUL, MN 55116
651-698-3208
4lttl2023 4:55:10 PM CDT Repair Order #L33297 Page:1
MILLS, AARON
1640 BAYARD AVE.
SAINT PAUL, MN 55116
Vehicle z 2Ot4 Ford Fusion 2,O L122 CID L4 DOHC
VIN :3FA6P0K95ER212701
Fleet #/Eriver:Created :41tL12023 6:32:51AM CDT
Completed : alLL/2023 4:55:08 pM
Service Writer : WJN
TaglState
Phone: 651-356-9402
MYN225/MN
Odometer In
Odometer Out
: 90286
: 90286
MOUNT AND BALANCE 2 TIRES ROTATE TO FRONT
h.DescriotionCode/Tech*
dF TR02 Advanta HPZ-01- 235/40R19 XL 98Y - Not Run-flat, Performance All SeasonJDS* MOUNTAND BALANCETIRE
.--MOUNTTIRE ON WHEELAND COMPUTERIZE SPIN BALANCE.
VALVE STEM
TIRE DISPOSAL
BKI<Z Wheel Lug Nut
Price
$263.10
$70.00
$10.00
$12.00
$71.96
Labor
Parts
Tires
Shop Supplies
Hazardous Material Charges
Charges
Sales Tax
Technician Code
JDS
Certification #
Approvals
Date & Time Total Amount . Authorized By
I hereby authorize the repair work herein set forth to be done along with the necessary material and agree that you are not
Employee
for loss or damage to vehicle or articles left in vehicle in case offire, theft or
streets, highways or elsewhere for the purpose of testing and/or lnspection.
48 hrs, after repalrs are completed WILL INCUR A $5.00 PER DAY
$70.00
$81.96
$263.10
$12.1s
$3.s0
$12.00
$29.36Sales Tax @ 7.875o/o
Repair Total
PAYMENT
BALANCE DUE
$472.O7
$0.00
$472.O7
any other cause beyond your control. I hereby grant you ,
An express garagekeeper's lien is hereby acknow{edged
SIORAGE FEE. '12 lVonth or'12,000 lVile Wananty On 1
Customer Signature
and/or your employees permission to operate the vehicle herein described
on above vehicle to secure the amount or repaks thereto. All Vehicles left
Repairs.
Price: $427.06