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McDonald I�I��ICE (JF CLAIM FORM to the City of Saint Pau����i��ota b�innesotf:Smte Statute 466.05 states that "...eveiy person...who claints damctges from any��utnicipaliry...sltdllrchi�s�t�c�j}l�nted to tlte gouerning 'vocly of the muiaicipulity H�ithin 180 days after the alleged loss or injury is discovered a notice stutin the tirne la e,and circurnstances tllereof,anct the aniount of compensatio�i or other relief dernanded. '�`���i d�,,,�,�y� Please complete this form in its entirety by clearly typing or printing your answer to each questian. If more space is �eeded,attach additional sheets. Please note that you will not be contacted by telephone tc�clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You wilt receive a written ac�knowledgement once your form is received. The process can take up to ten weei:s or Innger depending on the nature of your claim. This form must be signed,and both pages completed. If something daes not a�pply,write`N!A'. S�I�TD C�1��PLETED FORM AND OTHER DOCUMENTS TO: CIT� CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PA.UL, Ml�T 55102 F�irst Name �0�.`��GL�� Middle Initial �Last Name��d/�� �� Company or Business Name Are You an Insurance Company? Yes/No If Yes, Claim Number? Street Address �� r � ` �� d �6 ��10 i�� City__ �'��-�--�P(,,r.L/ :� State_ /y� 7ip Code�� �L� Daytime Phone ( j - Cell Phone (�}J� - � Evening Telephone(�) G� . b.�-�.-�t_��;�,� Date o�Accident/Injuiy or Date Discovered � � —' o�. 'me am/pm � '� �'ooa��►, ���J� �� Please st�te, ii�detail, what occurred(happened), and why you are submitting a ciaim. Please indicate why or how you fee the City of Saint Paul or its employees are in�tolved and/ox responsible for our damages. � - � . 0 Please check.the box(es) that most closely represent the reason for completing this form: C �1VIy vehicle was damaged in an accident ❑ My vehicle was damaged during a tow My vehicle was damaged by a pothole or condition of the street ❑ My vehicle�vas damaged by a plow L7 My vehicle was wrongfully towed and/or ticketed ❑ I was iniured on City property C7 OtYier type of property damage—please specify !A C� Other ty�e of injury—please specify i In order to process your claim youu need to include copies of all a�plicable docuYnents. i I~or the claims types listed below,please be sure to include the documents indicated or it wi11 delay the handling of y�ur claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keeg a copy f�r yourself before submitting your claim form. �Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds ti 500.00; or the actual bills and/or receipts for the 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 act�al bills and/ar 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 Forn� � . �� r . � `"` –�t-/s�L/ �� ' � .� , , � s ' ���� -�'��'�—�l// ..,�(/Y�J � �v�{ S/�o� -=��%��Q,� : �—� �ze�--��. ����-e� o � � .� � ����•G� . � . �..e� ; � .� , �� � � �..�,��,�, � , �--��' � /�-��-�- �� ��� � , � ���� , � _ , �� .� `�� � � � ��2t-Q-�� � i �./�j(� � ���d r � � ---��� � . � a-� �.�� - i � ' ,���---�- , �-'� . .�� �� ' � � �_ d ��7'� 1��.�j . � , . V �- E I i �- ��1.�-� � � , f � , , � �� �-�J���� 0 Failure to complete and return both pages wili result in delay in the handling af your claim. All C�aims—nlease complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes � Unknown (circle} If yes, what department or agency? Case#or report# Where di�l the accident or injury take place? Provide street address,cross street, intersection,name of park ar faci 'ty, closest land ark,etc Please be as detailed as possi le. If ne essary, atta�h a diagr . D � Please indicate the am unt you are seekin in compensation or whaX you would like t e i�y t o to r solv�th's claim to yau satisfaction. � � a� `�- ° -° � � �-��- LrG�-1- �� �%e�iele Claims— lease com lete this section S � O check box if this section does not a 1 Your Vehicle: Year Make Model License Plate Numbe L� State Co or Registered Owner Q�a,.� , a- � Driver of Vehicle � I � Area Damaged City Vehicle; Year Mak Model License Plate Number State Color _ ; Driver of Vehicle(City Employee's Name) Area Damaged Inie�rv Claims—please eomplete this section �check box if this 5ection does not anplv How were y�u zn�ured� What part(s} of your body were injured� Have you sought medical treatment? Yes No Planning to Seek 7'reatment(circle) When did you receive treatment? (provide date(s)1 Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No � �Vhen did you miss work? fprovide date(s)) j Name of your Employer: , Address Telephone I �Check here if you are attaching more pages to this claim form. Number Qf adaiitional pages�� �0.5� � By signaz�g this form,you are stating that all infornzation you have providec�is trece and correct to the best of your knowledge. Unsigned forms will not be processed. Suhmitting a false claim can result in prosecution. Date form was completed�// 9�/ �/ �'ri��t��P+1a�e of the Person who Completed this Form:�/� �� �(`��T ��/��� Signature of Person Making the Claim: , � Revised February 2011 � €��,�_�; T OPPERS AtJD MORE � .�� � 1000 9TH AUE �� e SOUT651�451-1808 �50 1948 iERMIHAI I.Q.: Invoice lERCHANT N � 03I24f12 g:39 AM Invoice No: 5693 UI SA Date; 3/24/2012 �K�K�Ic�k�i:�K�k**�K�K�KZ 15S MANUAL Order No:. 651-793-4309 MAIL ORDER BpT GH= 000249 Salespecson: ROD INU=000007 AUTH� 02403B TDTAL �984.52 �; � st GU5i01�ER COPV COVER#600-1996 CHEVROLET SILVERADO LB-8'BOX- 1.0 $759.0 0.00°/ $759.00 5����� �S �°� TD-Single T-Lock Rear poor 1. $0. 0.00°/ $0.00 TD-50/50 Side Slider Windows 1.0 $0.0 0.00°/ $0.00 ront Slider Windaw 1. $45.0 0.00°/ $45.00 12 Volt Interior Lite 1.0 $45.0 0.00°/ $45.00 lamped on installation 1 A $70. 0.00°/ $70.00 1.0 $0.0 0.00°/ $0.00 '� � � •Indicates non-taxable item Subtotal $919.00 T�a(7.13%) $65.52 Total $984.52 Deposit $984.52 Balance Due $0.00 Page 1 of 1 Top�er&Accessory Order ` Toppers &IbIore Date: �'" �� `� � � 1000 9th Avenue �outh ' �:�, ' �� Sales erson: � . South Saint Paul,MN SS7075 p � Phone: 651-451-1808 Sottrce: `� � : Fax: 651-451-1899 �. .: Install Time: � ._ ., : � www.toppersandrn�re.net �� �� '� ���� _ Serial#: � YOfJR.TRU�K,&S�1V AC�ESSORY STORE . `� �u���'�s I�arne'.�P O,#�Last} ����.�J�t�'�����4 � F�rst � �`��� . ;; � ; v „ � : � :. ,�(. � . x�°. ,� �c�cfi���� �,��� ��"�����r� ��? � �Ci��Sta�e ��. �"'��,� ��e�'�c�ne ���: ���� -���� COth��Phon�: , _ �Y �'ea�k c��� 1Vlode�: ��� _ , _� Cab�Bed� � � C�ilar: ��� _ �.�� _ _ . � � �� r ; �,�:�e � � � � � 'F}�is is�Iega.�and bind�fg eotrfra�t. � �~��r��;� �,�•�t�"��� � s ��� Ret�ns/�vace�lati�ns �3 e ' _ % �IQf'�F��tLS „ � � : 4 ; .. { . �1tr� �"ou�e�tal � _ �� ��� �r.��+��`✓�.. r Uu�t`'s�D�'s��'e�on r�t'�i�ab�e�tic��c��ai�' y! r. x ,�� 11C1�YPi�1 � �C �e�tUll.�k C2Il�e��f�$���'E�t7S�, � � '�; p�� t ��Q�fff;L 1CU�iE�tiPG���E3�$� x i 4> i� 9Q�� ��`E�fik�'.��C`l��j'�.� t� f;�-'ai. - i .� �' a �.�I'���}1' � ��tlatl���i� � ��" ��Fg sn�n���t�'er�aia ��`- ? � t�€��e�£,ea�cz�-�ca�n �,x :�',�, �' ��:� .� � �.� , ; �- 4 : � : ,�f x. y �,p � -�s -� ��'� � x s �L3.' �� 3 t� .��T��� ��}���5` �U 1Y.0 �.Q���+ ,� ;� � " �i��cf;�s�i�e�'br-�e���s sa� �e�� . ' 1 x ,#�� _ v-'�-�..� � 4 � ( ,.� � � �} ��f�.�Yk17t"[��t . ''�°'��� � 'w' : � � � T � sY � ; � �� �� �� '�ba'�� ' � �" ��� ��T���1'9f�i1��S ,f���'1� ,«.�x � � .� �u' ,..,�t :�; �^a�;_ an�'a�e�'F��e��Q!t�L1c���0€c��, ��s�c�s'��ssories "'"�" �- �.<`--�' _ �����rg2����e ° � �e�.�`&er) , fi�zs� �`a�e�s and Atfare n����'� �;: � .� €r�ui�tll �Ze�%e�Ci�� fc�r sucf��ge�t�,e�: _ wF1��o�re��r r�a-�.nt th,e v�lur�e.� Drsclau�ner at' War�ant�- �1�aler �e��ressly.`. cT�scTa�ms�.t�'`�atranties an�'ta�ncts��r�,�- c�it e�aaxau��c��ed by��i�z�.��;�: , � �fanufaei�ei�Qvaitr`ai�����u�l��ae���a�k t�' }� , ; f�e isianu�cti�er,�vhoat�eir t�c���lI; �� , .. _ : _,_` , , _ � : �de�ermi��ir�t�re item xs,t,��;�?u��r�ar= . ra�lt3'anc�#�iieri repairecl ar��aced.Ala�rte o€ I � tYi�i�varrats�ies caver glas��ire��ag�. _ � , R ` : . Bptyer ae�€ovSr�e�ge�ant#�gr���to fhe�Fio�e �ha�T�sstruc#toii """""'"' � � ���,,, �erms. _F�ag Fnsc�atian%utT�7ug �JS�!'��",,� '" ��` „ - � � , : � - � � � . , �nyer's Signatt�e �op�ha���s _ {- ���`�`T� � ;�' � Custotrier Ta�e/Self Insta�l ��_ B�yer assu�es sole respcznsibilty for tk�e %n= �, . '��SS Coupoitf�tll�i (-� sta�tatian of the t�uck;cap and�e pro�ier fun�- � � � � �iiin of the C2�fer Maunt Brake�ight��1VI$L} , `� Sa�es Tax, � "*"� in the topper in accardance with FederaT regu- k lation. SttEltOtal ;' � �, . .,� Cash, Card#, Check# Less I�ow� Payment Buyer's Signature " BALANCE www.radco.com QUOt@ �� Quote expires i Tt�,F,QG�sso�r �'el�te/� April 16,2012 12:�0 am , Ticket#: BLN-5298 Brian Hastings Ticket date: 3/17/12 Soles Station: BLN2 1502-99th Lane 763-783-2106 Blaine,MN 55434 fax 763-783-2109 Yo�rTuc�F,�Icc�sso�T�ros Ship to: Customer PO: Customer#: CASH Ship date: Ship-via code: Sis rep: Z Location: 800 Terms QuantiEy' ltem#" ` lrend Item# '` DescripEion` , ` �_. : �: , ` Pnce Unit�lag Ext.prc _ , , 1 800006GMC2 GM LB 88-98 RADCO SUPERSLIDER TOPPER $744.00 Each _ 744.00 � ��$ CANDYAPPLE RED $0.00 Each 0.00 1 880080 FRONT SLIDING WINDOW MITERED $40.00 Each 40.00 1 MRD Mitered Rear poor $0.00 EACH 0.00 1 880113 INSTALLATION-TOPPER/LID $75.00 Each 75.00 Ticket Order � *** QUOTE **' Sub total: 0.00 859.00 T�: Sub total: 859.00 0.00 61.20 T�: 61.20 Total: 920.20 Invoice1.rpt 10/5/2010 LPA �' — � � � ^ ° �� � ��,�� ,�����=�. � � � � �� ��"� { ', +. �S' � � ,,� s� � €�€ `` ��, r .� y � �` �} �" f � �: ��` �� �� -....� � �� �-'',�,�` ` , ; s � � � �a`� �1��. � <, 4 � � ,,�'' �; s., � � n !flVi�� f � �'' �� ��"' I Bi� � 6: W i� y�� : � ! � �� � ��, } ��. � t� �+�i+� � y ' 4}r�� I �di�� •: � ��� ���,�a�� � r'. 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