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�iE��l�EC�
JAN 2 � z0��
NOTICE OF CLAIM FORM to the City of Saint Paul, Minn�s������{
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shalt 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 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 pmvide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The prceess 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 ��-G��ti Middle Initial '�Last Name ``�►�L'�'�
�'ompany or Business Name 1 `� t�
Are You an Insurance Company? Yes/� If Yes, Claim Number? •
Street Address ���" ��'�d ��'
City S�- pau,t State ("��nh���' Zip Code�V��
Daytime Phone(��-) � ��Cell Phone( ) l��Evening Telephone(_) ��
Date of AccidenU Injury or Date Discovered�M�l-�1 Z� ���y Time ��''� 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 and/or responsible for your damages. I ��rn�
��e.�.l SYtOU� R�oU)s dx`�v�l�g dt,�ux� (�rc�xw Ave,�i;c rng►�nq chwni�S � sv�o�.�
�rv'et�s 4�c � � t�F. �t�� V�h.P,t,ti 1 �nJ�- � 'M
ve�cG��G 1cx�tX � �h -tan.e. _►� hat� -F� t�JtD� c� �� �.aw�,�t �f
� o-� cQu- �hc;�,��i,c. a�c� m Y � w�n.e��
1 rQ,�n Ov� - , 1 h�►c�d T�cx� u���h, mu r�n,tv�r m- �v�x s
S�fY-����Gt "i1MC � a �1'�� �� � 1n� �101A� o�iS"�dClY1A �1�.t1� C�tX'S �"�
�t�.ed. O�rl
Please check the box(es)that most closely represent the reason for completing this form: ��
❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow S�'��
❑ My vehicle was damaged by a pothole or condition of the street �J.My vehicle was damaged by a plow o�xx� 1'v�,us
❑ My vehicle was wrongfully towed and/or ticketed � I was injured on City property ���,��
❑ Other type of property damage—please specify ��� U`n��l�-s'
❑ Other type of injury—please specify N f A'�' °��'��
�c�, � �b�f
In order to process your claim vou need to include conies of all annlicable documents. � �''e`^`�
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 yourself before submitting your claim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for ihe 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 Injury claims: medical bills,receipts
O 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 ,
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease complete this section `�� �
Were there witnesses to the incident? Yes No Unknow (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No , Unknown (circle)
If yes,what department or agency? Case#or report#
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 detai ed as�ossible. If necessary, attach a diagram.
��ly' �1'U�'1� � �`. �OIMR� NII� ��(�
Please indicate the amount you are seeking in com ensation or what you would like the City to do to resolve t s claim
to your satisfaction.��•�' � T� �-� � r�'�'�r ������ 'PL� `�Y�e �-�� �
Vehicle Ctair►TS=please complete fhis section - �C.7 check�ox if this section does no�appIv -
Your Vehicle: Year �-o� Make �l."tV Y�'1 Model SL
License Plate Number �SiO-DS� _ State M Color �'�K �1��^�`
Registered Owner I�U��
Driver of Vehicle
Area Damaged r �S ��clr O�
City Vehicle: Year '��� Make �'A Model�/�
License Plate Number N 1l� State��R Color '���
Driver of Vehicle(City Employee's Name) ��A
Area Damaged N(�
In'ur Claims- lease com lete this section ❑check box if this section does not a 1
How were you injured? N �
What part(s)of your body were injured? ��l�
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? N 1� (provide date(s))
Name of Medical Provider(s): � fs
Address � � Telephone N/a
Did you miss work as a result of your injury? Yes No
When did you miss work? N�� (provide date(s))
Name of your Employer: _ �T _ __ss�
Address �� Telephone
(`�Check here if you are attaching more pages to this claim form. Number of additional pages�p��'s�"�
�� � �p�
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 � I�I�,�
Print the Name of the Person who Completed this Form: I�L�� ���v�
Signature of Person Making the Claim: � \W`�J
Revised February 2011
American Tire �Auto
. 1671 University Ave W INVOICE
� St. Paul, MN. 55104 51642
Phone-651-646-0035 Fax-651-646-6905
Thanks For Coming To American Tire! Org. Est.# 131704
lNVOICE Work Completed Date : 01/25/2012 Print Date : 01/25/2012
2000 Saturn -SL1
Ayoub, Rachel 1.9L, In-Line4,VIN (8)
1494 Grand Ave Lic#: 810DJZ Odometer In : 126418
Saint Paul, MN 55105 Unit#:
Home 612-735-0345 Vin# : 1G8ZG528XYZ163727
Cust ID : 17706 Ref#: Hat# : 11:50AM
Pa�t Description/Number Qty Sale Extended Labor Description Extended
DOOR MIRROR-USED,DRIVER REPLACE DRIVER SIDE MIRROR-
SIDE CUSTOMER STATES CITY SNOW PLOW
�26�57 1 AO 50.00 50.00 PLOWED NEXT TO VEHICLE DAMAGING
Shop Supplies 2.83 2.83 MIRROR
Technician Replaced Driver Side Mirror As Per
Customer Request.
DOOR MIRROR-Remove&Replace-Each 31.46
Hazardous Materials 1.34
****Recommendations****
ENGINE DEGREASE AND DYE
[Technicians:Chambers,Derek]
Org.Estimate S121.73 Revisions $0.00 Current Estimate $121.73 Additional Cost Revised Estimate Labor' 32.80
Parts: 52.83
Sublet: 0.00
Sub: 85.63
Tax: 3.81
Total: 89.44
[Payments- ] Bal Due: 89.44
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or yow employees
permission to operate the car or truck herein described on street,highways or elsewhere for the purpose to testing and/or inspection. An
express mechanic's lien is hereby acknowledged on above car or truck to secure the amount of repairs thereto. Warranty on parts and labor is
one year or 12,000 miles whichever comes first. Warranty work has to be performed in our shop&cannot exceed the original cost of repair.
SIGNATURE................................................................................................. Date......................................... Time.........................
Written By:Chambers,Derek Page 1 of 1 0�.».0�coPy��9n�Maa,en� Invoicl