Becerra-Carrillo REGEI�iED
NOTICE OF CLAIM FORM to the City ��YS�'i�t���ul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages fro��t�u� '� [�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 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 provide as
much information as necessary to explain your claim,and the amaunt of compeasation being requested. You will receive a
written aclutowledgement once your form is received. The process can take np to ten weeks or longe�depending�n tl�e
nature of yoar claim This form mnst be�ed,and boW pages completed. If something does not apMy,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CI1'Y HALL,SAINT PAUL,MN 55102
First Name �J�rq��b Middle Initial �c N� 6���r ra - �rrr j lo
Company or Business Name i
Are You an Insurance Company? Yes/No ff Yes,Claim Number? j
Street Address 8�� O r�' /9 VC�• ,
City �-�T� �CL� � State /�l IU� Zip Code 5 S l 0 ( I
Daytime Phone(�)��� ol o Cell Phone(�5�)�-510�/Evening Telephone(_) - �
Date of Accidenb Injury or Date Discovered � ��o2-G/�_Time�L�L_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 aze involved and/or responsible for your damages.
�I lJ�7, O Gt ' �
Please check the box(es)that most closely represent the reason for completing this form:
❑ y vehicle was damaged in an accident ❑My vehicle was damaged during a tow
My vehicl��uas dar.�aged by a pothole or condition of the street ❑My vehicle was damaged by a plow
Mv�et�cle wa�wrnngfully towed and/or ticketed ❑I was injured on City properiy
❑Other type of property damage—please specify
❑Other type of injury—please specify
In arder tc�pr�,4e;c y,��;��la;���� �e€� •`_•���t�s�•s�t�Dies of all applicable documents.
For the claims types listed below,please�$�?re�ir�rl��:�P t�aa.,a=rer�maFstg 1p�li�ata�y nr it u;i���1��rnQ ha��linD nf 'I
your claim. Documents WIIJL NOT be re��rned an�t,�r,,me th�pn���-�;,�n��.�P('it�;. Yn„ are Pn�a,�ra�ed t��?ep a
��uYy fcT;uurse;�i�ef�r�submitting your claim form.
�=• nr=���*�-a=��•=�==�'•.:�ims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
--- _ __-��- --
$500.00;or the actual bills and/or receipt�fc�r r�,P r?Yajr�
O Towing claims: legible copie�c�`�n;ii=-:�_ci f��#icu%��+i a±�r;C+s i�z liii}�N�s;?�i�=z F2icir�.
(7 ()thr r nrn;,wrty�t�,�„a�,�,�t�;�„�.r�q repair estimates if the damage exceeds$500.00;or the actual bills
�?a!nr r�r,�i:tt�:r t::,=r�n�:::-:�.�xv.��a t;st of da.maged items
r.r_., -
O Injury claims: medical b�lls,rY:;�iY�s
-�----- - �c,,-�---- --� -- -.- „ 7.,� ',!
Photographs are alway�-.-_------ -- -------_-_----_�t�='�-,���`-'---:j::?��`�ti12f 2�C!t VG TCLIIICI�Gl1.
Page 1 of 2—Please complete and return bot,h pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease comnlete 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 No Unknown (circle)
If yes,what department or agency? Case#or report# l�0 SS�O q �
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 detailed as poss ble. If necessary, h a di
�9/ �o rdc �Q. ,�.��1!��� 2PTVr�,���
Please indicate the amount you are seekin�in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �i�0 a
Vehicle Claims— 1 rnm lete this section �check box if this section dces not a 1
Your Vehicle: Year l��Make Model ro ee '
License Plate Number�9/ p K G State M�. Color (.0 h r� f� �
Registered Owner i f Q— a f f�
Driver of Vehicle �
Area Dama�ed ' �
City Vehicle: Year .�-° � Make �'orl� Model �rvV�
License Plate Number Qo1�i G2 State�Color �c
Driver of Vehicle(City Employee's Name)___�o vv�� n iF V i n c e✓� (���f.� ,
Area Damaged U h !l vr��.1 �, I
In�urv Claims—ulease comnlete this section �check box if this section does not annlv �
How were you injured?
I
What part(s)of your body were injured?
I
Have you sought medical treatment? Yes No Planning to Seek Treamnent(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s): 'i
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
�Check here if you are attaching more pages to this daim form. Number�additional pages�. (
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 prncessed
Submitting a false claim can resull in prosecution. Date form was eompleted `7��.30 -�O/�
Print the Name of the Person who Completed this Form: ���;� t'�P�P r� C�Y f t �l 0
Signature of Person Mal�ng the Claim: V e����p z f Q,� c��f t�\��j
Revised February 2011
Accideat Report Page 1 of 1
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http://www.dvslesupport.org/dvsinfv/accidentrecords 2008/Includes LE/PrintReportindiv... 4/1 8124 1 2
HIGHLAND AUTOSTAR COLLISION CENTER
2042 WEST 7TH ST.
ST. PAUL, MN 55116
OFFICE:651-699-0340 FAX:651-699-4953
FED TAX ID#41-1828627
***PRELIMINARY ESTIMATE"`*
04/27/2012 10:46 AM
' Owner _ .� .�_
Owner: SERGIO BECERRA-CARRILLO
Address: 891 YORK AVE Work/Day:
Home/Evening: (651)578-0170
City State Zip: Saint Paul, MN 55106 Cell: (651)755-5109
p .............�_._�...._....__..._......._,..__ ��_...�.,.__........,_ ...,......,.... ...._.,......_ �.........,..o> �............_.,......,_ �..................._._.....__�......�..._. �._ _....W.�.._._ -.........� , .... .... ...... _ _..
� Inspection `
_ _ ____ _�
Inspection Date: 04/27/2012 10:47 AM Inspection Type:
Primary Impact: Left Side Secondary Impact:
Appraiser Name: JOHN RITTER_JR Appraiser License#:
Address: 2042 W7TH ST Work/Day: (651)699-0340
FAX: (651)699-4953
City State Zip: Saint Paul,MN 55116 FAX:
Email: JOHNJRC�HIGHLANDAUTOSTAR.COM
___ ____
Repairer
������ ---����� Repairer: HIGHLAND AUTOSTAR �� � Contact: � ������ ���� ���
COLLISION
Address: 2042 7TH ST W Work/Day: (651)699-0340
City State Zip: ST PAUL, MN 551 1 6-31 07 FAX: (651)699-4953
Email: HA2042C�3POPP.NET
. ___ __
_ __ _ __ . �_.m._. _ _ ,
� Vehicle
1999 Jeep Grand Cherokee Laredo 4 DR Wagon
6cyl Gasoline 4.0
4 Speed Automatic
Lic.Plate: 491 DKG Lic State: MN
Lic Expire: VIN: 1J4G258S7XC735346
Veh Insp# : Mileage Type: Actual
Condition: Code: J7313B
Ext.Color: STONE WHITE Int.Color:
E�. Refinish: Two-Stage Int.Refinish: Two-Stage
Ext. Paint Code: PW1 Int.Trim Code:
Options
AM/FM Stereo Tape Air Conditioning Aluminum/Alloy Wheels
Anti-lock Brakes Bodyside Cladding Center Console
Cruise Control Dual Airbags Intermittent Wipers
Keyless Entry System Leather Steering Wheel Lighted Entry System
Power Brakes Power poor Locks Power Mirrors
Power Steering Power Windows Rear Window Defroster
Rear Window WipedWasher Roof/Luggage Rack Tachometer
Page 1 of 4
04/27/2012 10:54 AM
1999 Jeep Grand Cherokee Laredo 4 DR Wagon
Claim#: 04/27/2012 10:46 AM
Tilt Steering Wheel Tinted Glass VeloudCloth Seats
_.._. �� ._ __ � _.__._ �. _ ._.. .. _ _ _ �
' Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Strines And Mouldings
1 RI 79 Cladding,Front Fender LT R&I Assembly 0.3 SM
2 E 362 01 Cladding,Front Door LT 5FR21VF7AF $79.25 0.4 SM
3 RI 452 Cladding,Rear poor LT R&I Assembly 0.4 SM
Front End Panel And Lamps
4 RI 41 Headlamp Assembly LT R&I Assembly 0.2 SM
Front Bodv And Windshield
5 BR 103 13 Fender,Front LT Blend Refinish 2.1 RF
1.0 Blend
0.6 Two-stage setup
0.5 Two-stage
Front Doors
6 I 207 Door SheIl,Front LT Repair 5.0' SM
» INCLUDES ALIGN
7 L 207 Door SheIl,Front LT Refinish 2.4 RF
2.0 Surface
0.4 Two-stage
8 RI 562 W/Strip,Belt Outer LT R&I Assembly INC SM
9 E 360 N/Plate,Front Door LT 55155621AB $68.75 0.2 SM
10 RI 229 Mirror,0uter R/C LT R&I Assembly 0.3 SM
11 RI 215 Glass,Front Door T LT R&I Assembly 1.4 SM
12 RI 241 Chnl,Front Glass Upr LT R&I Assembly 0.3 SM
13 RI 227 Handle,Front Door Otr LT R&I Assembly 0.4 SM
Rear poors
14 BR 289 Pnl,Rear poor Outer LT Blend Refinish 1.0 RF
0.7 Blend
0.3 Two-stage
15 RI 309 W/Strip,Belt Outer LT R&I Assembly INC SM
16 RI 295 Glass,Rear poor T LT R&I Assembly 0.6 SM
17 RI 303 Channel,Rear Glass Run LT R&I Assembly 0.5 SM
18 RI 276 Rear Vent Glass R&I LT R&I Assembly 1.1 SM
19 RI 305 Handle,RR Door Outer LT R&I Assembly 02 SM
Manual Entries
20 SB HAZARD.WSTE. REM. Sublet Repair $6.00' SM
21 SB COVER CAR EXTERIOR Sublet Repair $7.00' RF
22 L CORROSION PROTECTION Refinish 0.5* RF
23 L FEATHER, PRIME, BLOCK Refinish 1.0` RF
24 L DENIB&BUFF Refinish 1.0` RF
24 Items
MC Message
01 CALL DEALER FOR EXACT PART#/PRICE
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
e _n_...�. ..u� � � _. �. �_ �
Estimate Total&Entries -_�- -- - �
Gross Parts $148.00
P t � tp . � ��Rn nn
Page 2 of 4
04/27/2012 10:54 AM
1999 Jeep Grand Cherokee Laredo 4 DR Wagon
Claim#: 04/27/2012 10:46 AM
Parts&Material Total $428.00
Tax On Parts Only @ 7.625°/a $11•29
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal(SM) $56.00 6.3 5.0 11.3 $632.80
Mech/Elec(ME) $90.00
Frame(FR) $80.00
Refinish(RF) $56.00 8.0 8.0 $448.00
Paint Materials $35.00
Labor Total 19.3 Hours $1,080.80
Sublet Repairs $13.00
Gross Total $1,533.09
Net Total $1,533.09
Alternate Parts Y/00/00/00/00/00 CUM 00/00/00;00/00 Zip Code:55116 Default
Recycled Parts NOT REQUESTED
Audatex Estimating 6.0.726 ES 04/27/2012 10:54 AM REL 6.0.726 DT 04/01/2012
Copyright(C)2011 Audatex North America,Inc.
1.8 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
YOU ARE AUTHORIZED TO MAKE THE ABOVE REPAIRS. I UNDERSTAND THAT PAYMENT IN FULL WILL BE DUE UPON RELEASE
OF
THE VEHICLE. PARTS PRICES ARE SUBJECTO TO INVOICE. I GRANT PERMISSION TO OPERATE MY VEHICLE FOR THE PURPOSE
OF
TESTING/INSPECTION. HIGHLAND AUTOSTAR IS NOT RESPONSBILE FOR LOSS OR DAMAGE TO THE VEHICLE OR ITS
CONTENTSIN
CASE OF FIRE,THEFf OR ANY CAUSE BEYOND YOUR CONTROL.AUTHORIZED
gy; DATE:
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANTJFACTURER OF YOUR VEHICLE.
A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Op Codes
' = User-Entered Value E = Replace OEM NG= Replace NAGS
EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus
ET= Partial Replace Labor EP= Replace PXN EU= Replace Recycled
TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = Two-Tone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish I = Repair IT = Partial Repair
CG= Chipguard RI = R&I Assembly P = Check
AA= Appearance Allowance RP= Related Prior Damage
Page 3 of 4
04/27/2012 10:54 AM
1999 Jeep Grand Cherokee Laredo 4 OR Wagon
Claim#: 04/27/2012 10:46 AM
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than
//!'�� the insured,claimant and others on a need to know basis in order to effectuate the claims processj without
� l7ud�t'�A Audatex's prior written consent.
a SoOera cwn�r.�tty
Copyright(C)2011 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 4 of 4
04/27/2012 10:54 AM
-. . BONFE'S AUTO SERVICE & BODY Workfile ID: 340718e7
REPAIR_CF
380 7TH ST W, SAINT PAUL, MN 55102
Phone: (651) 222-4458
FAX: (651) 224-8640
Preliminary Estimate
Customer: BECERRA, SERGIO
Written By: MIKE HOFF
Insured: BECERRA,SERGIO Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 09 Left T-Bone(Left Side)
Owner: Inspection Location: Insurance Company:
BECERRA, SERGIO BONFE'S AUTO SERVICE&BODY
REPAIR_CF
891 YORK AVE. 380 7TH ST W
ST. PAUL, MN 55106 SAINT PAUL, MN 55102
(651) 578-0170 Evening Repair Facility
(651)755-5109 Business (651)222-4458 Business
VEHICLE
Year: 1999 Body Style: 4D UN VIN: 1J4G25857XC735346 Mileage In:
Make: ]EEP Engine: 6-4.OL-FI License: Mileage Out:
Model: GRAND CHEROKEE 4X2 Production Date: State: Vehicle Out:
LAREDO
Color: WHITE Int: GREY Condition: Job#:
4 Wheel Disc Brakes Clear Coat Paint Keyless Entry Power Windows
Air Conditioning Cloth Seats Luggage/Roof Rack Rear Defogger
Aluminum/Alloy Wheels Console/Storage Overdrive Rear Window Wiper
AM Radio Cruise Control Passenger Air Bag Search/Seek
Anti-Lock Brakes(4) Driver Air Bag Power Brakes Stereo
Automatic Transmission Dual Mirrors Power Locks Tilt Wheel
Bucket Seats FM Radio Power Mirrors
Cassette Intermittent Wipers Power Steering
4/30/2012 8:54:50 AM 013793 Page 1
Preliminary Estimate
Customer: BECERRA, SERGIO
Vehicie: 1999 JEEP GRAND CHEROKEE 4X2 LAREDO 4D UN 6-4.OL-FI WHITE
Line Operation Description Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 R&I R&I bumper cover 1.3
3 FRONTLAMPS
4 R&I LT Headlamp assy Laredo, Sport 0.3
5 FENDER
6 Blnd LT Fender 1.0
7 R&I LT Fender liner 0.3
g R&I LT Lower cladding Laredo dark gray 0.2
9 FRONT DOOR
10 R&I LT Seal 0•2
N 11 * Rpr LT Door shell �4 Z•3
1Z Add for Clear Coat 0•9
13 R&I LT Belt w'strip outer 0.3
14 * Repl LT Lower cladding Laredo,Sport brownstone 1 79.25 0.4
15 Repl LT Nameplate"Grand Cherokee"silver 1 79.10 0.2
16 R&I LT Mirror heated GTF code 0.3
17 R&I LT Door glass Jeep 0.5
18 R&I LT Handle,outside Laredo,Sport black 0.3
19 R&I LT R&I trim panel 0.4
20 # Repl COVER CAR COMPLETE(2 TIMES) 1 14.00 T 0.2
21 # Repl CORROSION PROTECTION 1 15.00 T 0.5
22 # Repl HAZARDOUS WASTE REMOVAL 1 7.00 T
23 # Refn TINT COLOR TO SECURE PAINT MATCH 0.5
24 # Refn MASK&TAPE JAMBS 0.3
25 # Refn PRIME, BLOCK&FEATHER REPAIRS 1.0
26 # PART PRICES SUBJECT TO INVOICE 1
Z7 # **** POSSIBLE HIDDEN DAMAGE***** 1
SUBTOTALS 194.35 10.4 6.0
NOTES
Line 11: POSSIBLE ADDITONAL WILL ADVISE ONCE DOOR CLADDING IS REMOVED
4/30/2012 8:54:50 AM 013793 Page 2
. , Preliminary Estimate
Customer: BECERRA, SERGIO
Vehicle: 1999 JEEP GRAND CHEROKEE 4X2 LAREDO 4D UN 6-4.OL-FI WHITE
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 158.35
Body Labor 10.4 hrs @ $56.00/hr 582.40
Paint Labor 6.0 hrs @ $56.00/hr 336.00
Paint Supplies 6.0 hrs @ $35.00/hr 210.00
Body Supplies 6.3 hrs @ $3.00/hr 18.90
Miscellaneous 36.00
Subtotal 1,341.65
Sales Tax $ 194.35 @ 7.6250% 14.82
Grand Total 1,356.47
Deductible 0.00
CUSTQMER PAY 0.00
INSURANCE PAY 1,356.47
******************************************************************************
THIS IS A VISUAL ESTIMATE ONLY.
ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN OF VEHICLE.
NO GUARANTEE ON RUST WORK.
******************************************************************************
MINNESOTA FRAUD WARNING
A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is
guilty of a crime.
MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST
AN INSURER IS GUILTY OF A CRIME.
4/30/2012 8:54:50 AM 013793 Page 3
. Preliminary Estimate
Customer: BECERRA, SERGIO
Vehicle: 1999 JEEP GRAND CHEROKEE 4X2 LAREDO 4D UN 6-4.OL-FI WHITE
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE3WA99, CCC Data Date 4/16/Z012, and the parts selected are OEM-parts manufactured by the vehicles Original
Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM
(Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle
dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or
ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or
Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or
may have come from an alternate data source. Tilde sign (�) items indicate MOTOR Not-Included Labor operations.
The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure from the other
panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as AM. Used parts are
described as LKQ, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore.
NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times
listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times
are not included. Pound sign (#) items indicate manual entries.
Some 2012 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data
from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE estimator has a
complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
The fol�owing is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to be
repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical �abor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=6lend. BOR=Boron steel. CAPA=Certified
Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel. HYD=Hydroformed Steel.
Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF
International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace. R&I=Remove and Install.
R&R=Remove and Replace. Rpr=Repair. #tT=Rig#�t. SA�=San�wich�d St�el. Sect=Section. Subl=Sublet. UHS=UItra
High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Information Services Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASH
ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation
and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
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