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Azbill, MorganNOTICE 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 this completed form to the Saint Paul City Clerk's Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to "Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102". Claimant: First Name:M r(36"'-‘Last Name: 11.-b.1 I Please Indicate Your Pronouns: XShe/Her/Hers, 0 He/Him/His, 0 They/ Them/Theirs Company or Business Name: Thnimpsoo Is this claim being made by an Insurance Company? YES NO f yes, what is your Claim/File Number? Is this claim being made by an Attorney?(=D If yes, what is your File Number? "I'm c1/4-n a urhey , idol* have_ 'a -ctle If yes, provide your Insured's/ Client's Name: Street Address: \ 0-1 ca (>61 cca. City:Mknr\-e-4-0 `4-01 State: INAM Zip Code: S5-3(A Daytime/Work Phone: Cell Phone:(0 G S5 iscoverea y, c.tfck‹,v-v-,obv,, Date of Incident or Date Discovered (Must Complete): LA (4 123 Time: ()cc real, ly-1 or\ OriA \C.) CickgeCX cAnSsin SS 1,-) Please state, in detail, what happened that prompted you to file a Notice of Claim Form: 0, -k-rckristrn h -(1,11c Q.ci*e(11, 00 I crie r' rok tvAP Please state why or how you feel the City of Saint Paul is responsible for your Damages? SfYIGIc,k-e...A 0, cycAti\ V of ko1-e_ and crtkcYccA orly v--6vv\ ksst 0 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. 0 Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid. 0 Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid. 0 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. 0 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. 0 You were injured during a motor vehicle accident: please provide police report number, details about injury. 0 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 Claim Form. Failure to complete and return both pages will result in delays. Revised March 2023 This section must be completed for all claims. Is there a police report for this incident? YES If yes, please provide the police repo ca number: 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: From of Landvnck 01- (Dek-vt) e&,-) rz; c_Q crk- — (vvi-evc,:e ck- k-orN What would you like to see happen to resolve this claim to your satisfaction? ‘2-€- Vo-V1R- m?Lairs or n'\I( inroo4 C Nc— 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: r2- 02-1 Make:Teti C DX-e-42_ Model: ‘-color: Wk7\ License Plate #: f24---kAq State vehicle is registered in: Registered owner of vehicle: 1\40 re's 0,0 Atbil Driver: MO r9Gt b 1 Area(s) damaged: v\ sk/Y)k. ss V-• If a City vehicle was involved, License Plate #: Color: Was there City insignia on the vehicle? YE Driver's Name: Other property damaged: For injury claims of any type. What part of your body was injured? 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: 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: Signature of Person submitting this form: t Relationship of person signing to Party making the claim: Date document is being signed:C4'2 123 Revised March 2023 CUSTOMER #: 1478033 MORGAN KAY AZBILL 13107 GREENWOOD RD MINNETONKA, MN 55343 HOME: CONT:612-296-7851 BUS: CELL:612-296-7851 269016 *INVOICE* PAGE 1 Walser I Chrysler, Jeep, Dodge 314 Mainstreet Hopkins, MN 55343 Service Phone: 952-935-2400 Fax: 952-945-7239 www.walser.com SERVICE ADVISOR: 317 JAMES SOCHKO COLOR YEAR MAKE/MODEL VIN LICENSE MILEAGE IN / OUT TAG WHITE 21 JEEP GRAND CHEROKEE 1C4RJFAG6MC601937 36620/36650 T1801 DEL. DATE PROD. DATE WARR. EXP.PROMISED PO NO.RATE PAYMENT INV. DATE 02DEC22 DE 10:30 03MAY23 VMC 05MAY23 R.O. OPENED READY OPTIONS: SOLD-STK: 14BY642P DLR: 65454 ENG:3.6 _Liter TRN:AUTO 06:02 03MAY23 09:45 05MAY23 LINE OPCODE TECH TYPE HOURS LIST NET A Adv Diag AT [CUSTOMER STATES THAT THE VEHICLE HIT A LARGE POTHOLE AND BROKE THE TRANSMISSION PAN. HAD IT REPLACED BUT SEEMS TO BE SHIFTING HARD AND STALLS AT TIMES. INSPECT AND REPORT] CAUSE: Transmission fluid level low ID4 Adv Diag AT 11693 CP 1.00 190.00 190.00 PARTS: 0.00 LABOR: 190.00 OTHER: 0.00 TOTAL LINE A: 190.00 Transmission fluid level low Drove the vehicle into the shop. Scanned the vehicle and found no transmission related DTC's. Lifted the vehicle and there was an audible whine noise from the transmission. It sounded like a transmission pump with aerated fluid passing through it. Checked the transmission fluid level and it was low. The first step is to the the transmission fluid to the proper level and the re-evaluate,**************************************************** B No campaigns due at this time CA1 No campaigns due at this time 11693 CP 0.00 0.00 0.00 PARTS: 0.00 LABOR: 0.00 OTHER: 0.00 TOTAL LINE B: 0.00 **************************************************** C Multi-point inspection (according to maintenance interval) MPI Multi-point inspection (according to maintenance interval) 11693 CP 0.00 0.00 0.00 PARTS: 0.00 LABOR: 0.00 OTHER: 0.00 TOTAL LINE C: 0.00 **************************************************** D** Wiper Blade (OEM) - Replace Rear MA52 Wiper Blade (OEM) - Replace Rear 11693 CPM 0.10 1 68197131AA BLADE-REAR WIPER PARTS: 23.99 LABOR: 9.99 OTHER: Removed and replaced rear wiper blade. **************************************************** E** 8-speed fluid fill and check CAUSE: Transmission fluid level low TOTAL 9.99 9.99 28.55 23.99 23.99 0.00 TOTAL LINE D: 33.98 ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED Thank you for this opportunity to serve you. It is our aim to perform all the repairs requested on this repair order to your complete satisfaction. If our service was satisfactory tell your friends. If not please tell us immediately. "Any warranties on the products sold hereby are those made by the manufacturer. The seller WALSER CHRYSLER JEEP DODGE hereby expressly disclaims all warranties, neitherexpress or implied, including any implied warranty of merchantability or fitness for a particular purpose, and neither assumes nor authorizes any other person to assume for itany liability in connection with the sale of said products." DESCRIPTION LABOR AMOUNT TOTALS PARTS AMOUNT MISCELLANEOUS SUBLET AMOUNT SHOP FEES TOTAL CHARGES DISCOUNT SALES TAX x CUSTOMER SIGNATURE PLEASE PAY THIS AMOUNT Copyright 201K CDK Global, LLC SERVICE INVOICE TYPE 2- SI2C IMAGING CUSTOMER COPY CUSTOMER #: 1478033 MORGAN KAY AZBILL 13107 GREENWOOD RD MINNETONKA, MN 55343 HOME: CONT:612-296-7851 BUS: CELL:612-296-7851 269016 *INVOICE* PAGE 2 Walser I Chrysler, Jeep, Dodge 314 Mainstreet Hopkins, MN 55343 Service Phone: 952-935-2400 Fax: 952-945-7239 www.waiser.com SERVICE ADVISOR: 317 JAMES SOCHKO COLOR YEAR MAKE/MODEL VIN LICENSE MILEAGE IN / OUT TAG WHITE 21 JEEP GRAND CHEROKEE 1C4RJFAG6MC601937 36620/36650 T1801 DEL. DATE PROD. DATE WARR. EXP.PROMISED PO NO.RATE PAYMENT INV. DATE 02DEC22 DE 10:30 03MAY23 VMC 05MAY23 R.O. OPENED READY OPTIONS: SOLD-STK : 14BY64 2P DLR : 6 5 4 5 4 ENG:3.6_Liter TRN:AUTO 06:02 03MAY23 09:45 05MAY23 LINE OPCODE TECH TYPE HOURS MA001 8-speed fluid fill and check 11693 CP 1.00 190.00 3 68218925AB FLUID-AUTOMATIC TRANSMISSION 35.50 35.50 PARTS: 106.50 LABOR: 190.00 OTHER: 0.00 TOTAL LINE E: 36650 Transmission fluid level low Filled the transmission with the engine off. Ran the engine to get the transmission fluid temp over 86 degrees. Performed the 8 speed fluid fill procedure. Road tested the vehicle to the the transmission fluid temperature over 180 degrees and purge and air from the cooler and lines. Performed the transmission quick learn procedure. Let the transmission cool until the fluid temperature was lower then 86 degrees. Performed the 8 speed fluid fill procedure again. In all added 3 quarts of fluid to the transmission. Road tested the vehicle and the transmission is shifting normally at this time. The vehicle did not stall. with the quick learn the transmission adaptives are reset. It can take 500-1000 miles of normal driving for the transmission to adapt or learn for optimal shift quality. Repair complete. **************************************************** LIST ******************************************************************* ESTIMATE: 635.35 04MAY23 20:02 SA: 317 CONTACT: ******************************************************************* ******************************************************************* ESTIMATE: 190.00 CONTACT: ******************************************************************* 03MAY23 06:02 SA: 317 NET TOTAL 190.00 106.50 296.50 ********THE FOLLOWING WORK WAS RECOMMENDED BUT NOT PERFORMED******************* DESCRIPTION: BR81 Brake Pads (OEM) and Rotors Rear - Replace REASON DENIED: DEC ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED Thank you for this opportunity to serve you. It is our aim to perform all the repairs requested on this repair order to your complete satisfaction. If our service was satisfactory tell your friends. If not please tell us immediately. "Any warranties on the products sold hereby are those made by the manufacturer. The seller WALSER CHRYSLER JEEP DODGE hereby expressly disclaims all warranties, neither express or implied, including any implied warranty of merchantability or 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 said products." DESCRIPTION LABOR AMOUNT TOTALS PARTS AMOUNT MISCELLANEOUS SUBLET AMOUNT SHOP FEES TOTAL CHARGES DISCOUNT SALES TAX x CUSTOMER SIGNATURE PLEASE PAY THIS AMOUNT CopyrignI 2014 CDK Global, LAX SERVICE INVOICE TYPE 2 - SI2C IMAGING CUSTOMER COPY CUSTOMER #: 1478033 MORGAN KAY AZBILL 13107 GREENWOOD RD MINNETONKA , MN 55343 HOME: CONT:612-296-7851 BUS: CELL:612-296-7851 269016 Walser I Chrysler, Jeep, Dodge *INVOICE* PAGE 3 314 Mainstreet Hopkins, MN 55343 Service Phone: 952-935-2400 Fax: 952-945-7239 www.walser.com SERVICE ADVISOR: 317 JAMES SOCHKO COLOR YEAR MAKE/MODEL VIN LICENSE MILEAGE IN / OUT TAG WHITE 21 JEEP GRAND CHEROKEE 1C4RJFAG6MC601937 36620/36650 T1801 DEL. DATE PROD. DATE WARR, EXP.PROMISED PO NO.RATE PAYMENT INV. DATE 02DEC22 DE 10:30 03MAY23 VMC 05MAY23 R.O. OPENED READY OPTIONS: SOLD-STK : 14BY642P DLR : 65454 ENG:3.6_Liter TRN:AUTO 06:02 03MAY23 09:45 05MAY23 LINE OPCODE TECH TYPE HOURS ,PERSON CONTACTED: MORGAN AZBILL COMMENTS: None RECOMMENDED BY: 317 SOCHKO „ LINE ASSOCIATED: LIST NET TOTAL DENIAL ADDED BY: 317 SOCHKO ESTIMATE: 611.00 ********************************************* * *CASH VMC DISC AE CHK CHG *** ********************************************* THANK YOU FOR YOUR BUSINESS ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED Thank you for this opportunity to serve you. It is our aim to perform all the repairs requested on this repair order to your complete satisfaction. If our service was satisfactory tell your friends. If not please tell us immediately. "Any warranties on the products sold hereby are those made by the manufacturer. The seller WALSER CHRYSLER JEEP DODGE hereby expressly disclaims all warranties, neither express or implied, including any implied warranty of merchantability or 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 said products." CUSTOMER SIGNATURE DESCRIPTION TOTALS LABOR AMOUNT 389.99 PARTS AMOUNT 130.49 MISCELLANEOUS 0.00 SUBLET AMOUNT 0.00 SHOP FEES 43.87 TOTAL CHARGES 564.35 DISCOUNT 0.00 SALES TAX 9.82 PLEASE PAY THIS AMOUNT 574 17 Copyright 2010 CDK Glohel, PLC SERVICE INVOICE TYPE 2 • SI2C • IMAGING CUSTOMER COPY meineke DOING CAR CARE RIGHT Meineke - 2588 10500 Excelsior Blvd Hopkins, MN 55343 (952) 641-3386 shop.2588@meineke.net htt ps://www.meineke.com/locations/mn/hopkins- 2588/ Invoice for RO #256504 Service Advisor: Jeff Kolb Posted Date: 04/11/23 at 04:08 PM CDT Client: MORGAN AZB ILL Vehicle: 2021 Jeep Grand Cherokee L Laredo MORGAN AZBILL 2021 Jeep Grand Cherokee L Laredo 3.6L 6Cyl RO #256504 1 307 GREENWOOD RD FLEX ERC Naturally Aspirated 55343 VIN: 1C4RJFAG6MC601937 Phone: (612) 296-7851 License: 9RK419 Color: N/A Odometer In: 35000 / Out: 35000 Client concerns: • HIT A POTHOLE. LATER SAW A LARGE PUDDLE OF FLUID IN THE PARKING GARAGE. WENT TO PUT IN DRIVE OR REVERSE WOULDNT SHIFT START STOP NOT READY LIGHT KEEP BLINKING 1 - FREE INSPECTION (PER CUSTOMER COMPLAINT) Labor. FREE INSPECTION (PER CUSTOMER COMPLAINT) 3 Approved on 04/04/23 at 05:54 PM CDT 0 TECH: N Norton Moo 0 2 - TRANSMISSION PAN Labor. Parts: Discount: ATF GOLD - TRANSMISSION FLUID TRANS PAN PAN AND FILTER 50 OFF OVER 500 3 Approved on 04/06/23 at 03:10 PM CDT TECH: N Norton 9.5 $9.99 $447.00 $94.91 1 $356.06 $356.06 -$50.00 Subtotal $847.97 + es t. Tax $30.17 $878.14 RO Fees Fee:Shop Supplies $40.59 Subtotal $40.59 All Meineke repairs are covered by a nation wide 12 month 12,000 mile warranty. For details please go to website: https://www.meineke.com/about/customer-service/warranty/ Total Repair Order & Signature: X Total Labor: Total Parts: Total Fees: Discounts: Subtotal: Taxes: Grand Total: BALANCE DUE: $447.00 $450.97 $40.59 -$50.00 $888.56 $33.23 $921.79 $0.00 PAID Completed Transactions 04/11/23 CARDHOLDERNISA $921.79 Credit Card Visa****2381 Payment Auth: 011012 Contactless Visa AID:A0000000031010 Meineke - 2588 - RO# 256504 Printed on 04/11/23 - Page 1 of 2 04/04/23 04/04/23 SQ 'ELITE TOWING OF MINNEgosq.com MN 5319.13 #24692162Y32YP8A0E Details Billing location: gosq-com, MN Purchase Mode: MANUALLY ENTERED Dispute this transaction I Manage dispute WAI.SER i HASLER JEEP 314 MAIN STREET HOPKII,,S, MN 55343 05/0512023 16:52 55 CREDIT CARD VISA SALE Card XXXXXXXXXXXC81 Chip Card: VISA RENT MD: A0000000031110 ATC: OC ARQC: BAE 76E8E456a tO8 SEQ #: 19 Batch #: 3(24 INVOICE 269(46 Approval Code: 005E39 Entry Method: Chip Read Mode: SALE AMOUNT $57,1,17 CUSTOMER COPY