Dudley, Samuel (2)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
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 compensation
or other relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question. If you have additional documentation you may add those
documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission is to the Saint Paul City Clerk’s Office. You may email, fax (651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”
Individuals: First Name ____Samuel________________________ Last Name _______Dudley__________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☒_ They/ Them/Theirs ☐
Company or Business Name: ______________________________________________________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number?: _____________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: _________495 Summit Avenue_________________________________________________________________
City: ____Saint Paul______________________________ State ____MN_______________ Zip Code ____55102_________
Daytime/Work Phone _______________________________ Cell Phone _____404-702-1397_____________________
Date of Incident or Date Discovered (Must complete) 4/21/2023 Time _05:00 am________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Hit an unmarked pothole on 7th Street W
and Montreal Avenue in Saint Paul, MN._____________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _The road was not properly maintained, and
the hazard was unmarked. The City knew or should have known the flaw existed but failed to remedy it in a timely manner. Hitting
the hazard caused the vehicle damage because the road was improperly maintained. _____________________________
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.
☐Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
☒Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid.
☐Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from Impound Lot, and two estimates for repairs or actual bill that has been paid.
☐Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or
actual bill that has been paid.
☐Property damage: please provide two estimates for repairs or actual bill that has been paid.
☐You were injured during a motor vehicle accident: please provide police report number, details about injury.
☐You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury.
This section must be completed for all claims.
Is there a police report for this incident? NO If yes, please provide the police report case number ____________________
Revised December 2021 If 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.
on 7th Street W at the intersection with Montreal Ave in Saint Paul, MN______________________________________
Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your satisfaction? _____Compensation for damages of
$703.22_________
Were there witnesses to this incident? Please provide names and contact phone numbers.
______________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year ___2016___ Make ______Mercedes___________ Model ___E350_________________ Color
__Blue______________
License Plate # ______ 235 XVU _______________ State vehicle is registered in ___MN_____________________
Registered owner of vehicle _Samuel Dudley___________ Driver ___Samuel Dudley___________________________
Area(s) damaged ____Wheels and tires__________________________________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________
Other property damaged: ___________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _____N/A_____________________________________________________________________
Did you go to the emergency room or urgent care? Yes No Where? _________________________________________________
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?___________________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages. ___4 Pages: 1) paid invoice for
repair (3 pages) and 2) pictures of the unmaintained road hazard (1 page)___________________
By signing this 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: _______Samuel Dudley_________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 5/24/2023
Revised December 2021
CUST;MER #: 8013299
SAM DUDLEY
495 SUMMIT AVE
SAINT PAUL, MN 55102-2692
HOME:404-70 2-1397 CONT:404-702-1397
BUS· CELL·404-702-1397
COLOR YEAR MAKE/MODEL
GREY 16 MERCEDES-BENZ E350 w
32179
/h MORRIE'S
0
Mercedes-Benz
*INVOICE*
MORRIE'S MERCEDES-BENZ OF ST. PAUL
2780 Maplewood Drive
PAGE 1
SERVICE ADVISOR·
VIN
WDDHF8JB1GB231 042
Maplewood, MN 55109
Main: (651) 217-8700
Service Direct: (651) 217-8751
Fax: (651 I 766-2323
www.mercedesbenzofstpaul.com
2220 KIMBERLY SANCHE Z
LICENSE MILEAGE IN /OUT
39102/39103
TAG
TW327
DEL. DATE PROD. DATE WARR. EXP. PROMISED PO NO. RATE PAYMENT INV. DATE
01JAN16 DI 17:00 24APR23 0.00 VMCD
R.O. OPENED READY OPTIONS: ENG:3.5 LITER -
15 :07 24APR23 09 :47 27APR23
LINE OPCODE TECH TYPE HOURS LIST NET
A CUSTOMER STATES, DRIVERS FRONT TIRE
TIRE ARE IN THE TRUNK. PLEASE
CS CUSTOMER STATES
HAS SIDEWALL DAMAGE. WHEEL AND
CHECK AND ADVISE.
4 8 55 C
1 Q-8-40-0463 B07-163000 TIRE
CONTI PROCONTACT MO BW SKU 0352882
1 TDF TIRE DISPOSAL FEE
PARTS: 295. 00 LABOR: 0. 00 OTHER:
LEFT FRONT TIRE HAS GASH IN SIDEWALL, WILL REQUIRE
WHEEL IS BENT AS WELL AND WILL NEED REPAIR.
0.00
300.00 295 .00
0.00 0 .00
0 .00 TOTAL LINE A:
REPLACEMENT.
****************************************************
B VEHICLE HEALTH REPORT
VHR VEHICLE HEALTH REPORT
4 855 C
PARTS: 0.00 LABOR: 0.00 OTHER:
0 .00
0.00 TOTAL LINE B:
****************************************************
C** MOUNT /BALANCE 1 TIRE (LF)
, MNTBALl MOUNT /BALANCE 1 TIRE
4855 C 34.00
PARTS: 0 .00 LABOR : 34.00 OTHER: 0.00 TOTAL LINE C:
(. 5HRS ) (4855 ) REPLACED LEFT
AFTER REPAIR.
FRONT TIRE DUE TO DAMAGE. TEST DROVE
****************************************************
D** PERFORM WHEEL STRAIGHTENING -ONE WHEEL (LF)
WRl PERFORM WHEEL STRAIGHTENING -ONE WHEEL
4 8 55 C 120.00
PARTS : 0. 00 LABOR :. 120. 00 OTHER: 0 . 00 TOTAL LINE D:
(. 3HRS) (4855 ) STRAIGHTENED LEFT FRONT WHEEL AFTER FINDING WHEEL
BENT.
****************************************************
E** 4 WHEEL ALIGNMENT
FWA 4 WHEEL ALIGNMENT
4855 C
PARTS: 0.00 LABOR: 185.00 OTHER:
185.00
0.00 TOTAL LINE E:
WARRANTY DISCLAIMER, ALL PARTS AND ACCESSORIES ARE SOLD AND ALL REPAIRS ARE •SHOP SUPPLY COSTS: DESCRIPTION PROVIOEO BY fRE DEALERSHIP AS-IS. THE DEALERSHIP HEREBY EXPRESSLY DISCLAIMS ALL We have added a charge WARRANTIES. EXPRESS AND ~IED. INCLUDING ANY IMPLIED WARRANTIES OF equal to 14% of the LABOR AMOUNT MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. AND NEITHER ASSUMES NOR
AUTHORIZES ANY OTHER PERSON TO ASSUME FOR IT ANY LIABILITY IN CONNECTION WITH THE total cost of labor and PARTS AMOUNT SALE OF PARTS OR PRODUCTS OR THE REPAIR. THE ONLY WARRANTIES ON PARTS AND parts, not to exceed
ACCESSORIES OR REPAIRS ARE THOSE WHICH MAY BE OFFERED BY THE VEHICLE $50.00, to the Repair GAS, OIL, LUBE
MANUFACTURER OR THE PARTS MANUFACTURER OR DISTRIBUTOR AND ONLY SUCH Order for shop supplies SUBLET AMOUNT MANUFACTURER OR DISTRIBUTOR SHALL BE LIABLE FOR PERFORMANCE UNDER SUCH used in connection w ith WARRANTIES. CUSTOMER SHALL NOT BE ENTITLED TO RECOVER FROM THE DEALERSHIP ANY CONSEQUENTIAL DAMAGES, DAMAGES TO PROPERTY. DAMAGES FOR LOSS OF USE, LOSS OF this repair. MISC. CHARGES •
TIME, LOSS OF PROFIT OR INCOME, OR ANY OTHER INCIDENTAL DAMAGES. ALL PARTS ARE NEW TOTAL CHARGES By signing below, you acknow ledge that you were notified of and authorized the
Dealership to perform the services/repairs itemized in this Invoice and that you received ORIGINAL EQUIPMENT LESS INSURANCE (or had the opportunity to inspect) any replaced parts as requested by you. The vehicle PARTS UNLESS
is being returned to you in exchange for your oavment of the Amount Due. OTHERWISE INDICATED. SALES TAX
DATE CUSTOMER SIGNATURE AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE PLEASE PAY
THIS AMOUNT
D~AP. 2021 COi( Olobral, LLC (01/21) SERVICE INVOICE TYPE 2 -2S12C . "AS-IS". MN -9698095 CUSTOMER COPY
27APR23
TOTAL
0.00
2 95 .00
0.00
295 .00
0.00
0.00
3 4 .00
34 .00
120 .00
120 .0 0
185.00
185 .00
TOTALS
. ...
CUST0 MER #: 8013299 32179
/h MORRIE'S
(9
Mercedes-Benz
*INVOICE* MORRIE'S MERCEDES-BENZ OF ST. PAUL
2780 Maplewood Drive
SAM DUDLEY
495 SUMMIT AVE
SAINT PAUL, MN 55102-2692
HOME:404-702-1397 CONT:404-702-1397
BUS· CELL-404-702-1397
COLOR YEAR MAKE/MODEL
GREY 16 MERCEDES-BENZ E350 w
PAGE 2
SERVICE ADVISOR·
VIN
WDDHF8JB1GB231042
Maplewood, MN 55109
Main: (651) 217-8700
Service Direct: (651 I 217-8751
Fax: (651 I 766-2323
www .mercedesbenzofstpaul.com
2220 KIMBERLY SANCHEZ
LICENSE MILEAGE IN / OUT
39102/39103
TAG
TW327
DEL. DATE PROD. DATE WARR. EXP. PROMISED PO NO. RATE PAYMENT INV. DATE
01JAN16 DI 17:00 24APR23 0.00 VMCD
R.0. OPENED READY OPTIONS: ENG:3.5 LITER -
15:07 24APR23 09:47 27APR23
LINE OPCODE TECH TYPE HOURS LIST NET
(4855) (2.4HRS) COMPLETED 4 WHEEL ALIGNMENT, AFTER ADJUSTMENTS WERE
MADE, CONNECTED XENTRY SDS AND PERFORMED NECESSARY RE LEARNS. TEST
DROVE VEHICLE AFTER ALIGNMENT. VEHICLE DRIVES STRAIGHT WITH LEVEL
STEERING WHEEL ON A LEVEL ROAD.
****************************************************
CUSTOMER PAY SHOP CHARGE FOR REPAIR ORDER
0
0
WARRANTY DISCLAIMER: ALL PARTS AND ACCESSORIES ARE SOLD AND ALL REPAIRS ARE PROVIDED BY TAE DEALERSHIP AS-IS. THE DEALERSHIP HEREBY EXPRESSLY DISCLAIMS ALL WARRANTIES, EXPRESS AND 7};ll!UED, INCLUDING ANY IMPLIED WARRANTIES OF
MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, AND NEITHER ASSUMES NOR AUTHORIZES ANY OTHER PERSON TO ASSUME FOR IT ANY LIABILITY IN CONNECTION WITH THE SALE OF PARTS OR PRODUCTS OR THE REPAIR. THE ONLY WARRANTIES ON PARTS AND
ACCESSORIES OR REPAIRS ARE THOSE WHICH MAY BE OFFERED BY THE VEHICLE MANUFACTURER OR THE PARTS MANUFACTURER OR DISTRIBUTOR AND ONLY SUCH MANUFACTURER OR DISTRIBUTOR SHALL BE LIABLE FOR PERFORMANCE UNDER SUCH WARRANTIES. CUSTOMER SHALL NOT BE ENTITLED TO RECOVER FROM THE DEALERSHIP ANY
CONSEQUENTIAL DAMAGES. DAMAGES TO PROPERTY, DAMAGES FOR LOSS OF USE, LOSS OF TIME, LOSS OF PROFIT OR INCOME, OR ANY OTHER INCIDENTAL DAMAGES.
By signing below, you acknowledge that you were notified of and authorized the
Dealership to perform the services/repairs itemized in this Invoice and that you received
(or had the opportunity to inspect) any replaced parts as requested by you. The vehicle
is being returned to you in exchange for your payment of the Amount Due.
*SHOP SUPPLY COSTS:
We have added a charge
equal to 14% of the
total cost of labor and
parts, not to exceed $50.00, to the Repair
Order for shop supplies
used in connection with
this repair.
ALL PARTS ARE NEW
ORIGINAL EQUIPMENT
PARTS UNLESS
OTHERWISE INDICATED.
DATE CUSTOMER SIGNATURE AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE
D~AP. 2021 COK GlobH1, LLC 1011211 SERVICE INVOICE TYPE 2 -2s12c -·As-1s· -MN• 9698055 CUSTOMER COPY
DESCRIPTION
LABOR AMOUNT
PARTS AMOUNT
GAS, OIL, LUBE
SUBLET AMOUNT
MISC. CHARGES •
TOTAL CHARGES
LESS INSURANCE
SALES TAX
PLEASE PAY
THIS AMOUNT
27APR23
TOTALS
TOTAL
4 7.46
20.28
1 48
339.00
295.00
0.00
0.00
47.46
68 1 .46
0.00
21.76
703.22
Mercedes-Benz of St. Paul
2780 US-61
Maplewood , MN 5 5109
(651) 483-2681
Customer Information:
Sam Dudley
xxxxxxxxxxxxxxx
XXXXXXXXX XX X:XX02
(XXX) XXX-X397
Description of Product/Services
Service Performed
Payment Details:
Paid On: Thursday, April 27, 2023 05 :52 PM
Credit Card: :XXXXXXXXXXXX6156 exp XX
/XXXX
Card Type: Visa
Cardholder Name: samueldudley
Payment Type: Manual
Confirmation #: 060211
Dealer Associate: Kim Sanchez
Cashier: Kaine Thibodeau
THANK YOU!
Mercedes-Benz of St. Paul
RECEIPT
Invoice Details:
Invoice #: H4PDVNXDJ0
Invoice Date: Thursday, April 27, 2023 05:52
PM
Repair Order/Ref#: 3 2179
Amount
$ 703.22
----------------------
Customer Signature
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