Loading...
Gomez NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State St¢tute 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¢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 amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process 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 ; I Y' Middle Initial � Last Name Z ���d Company or Business Name 2�12 Are You an Insurance Company? Yes� If Yes, Claim Number? Street Address �y � ��1 � �'���� � U _ �� C�� C'��'�� City � ' �c�.;� State � 1� Zip Code 5 5 � � � Daytime Phone (���)}��'W�{ Cell Phone �� ���g��� Evening Telephone(_�'��--' Date of Accidentl Injury or Date Discovered d 1 Time 11, am pm 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. Ple 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 ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage—please specify � Other type of injury—please specify In order to process your claim vou need to include copies of all applicable documents. j i For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of � your clairn. Documents WII.,L 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 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 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-please 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 Unlazown (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 detailed as possible. If necessary, attach a diagram. Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year ' O� 3 Make_ � � . Model � v� v 6z c� License Plate Number F�`" b' v State '�Color �r c.� Registered Owner c� .Qi w ,� v�L Driver of Vehic`le r Area Iaamaged ' „ ' e �^ i�^ ti City Vehicle: Year � Ma e Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'ur Claims- lease com lete this section ❑ check box if this section does not a 1 How were you injured� c� �� �,,� e � � c• �r� What part(s)of your body were injured? Have you sought medical treatment? es Planning to Seek Treatment(circle) ' When did ou receive treatment?. (provide date(s)) Y Name of Medical Provider(s): C ��� c � � 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 claim form. Numher of 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 processed. Submitting a false claim can result in prosecution. Date form was completed � I � � � �- Print the Name of the Person who Completed this F m: e,'(i Vl r �O t�t/�-t Signature of Person Making the Claim: Revised February 2011 Accident Report Page 1 of 1 � ���: � � ��-� o izzsi�2� r� p Mrt.1MWtlM PJBPPOP YEMRE! 14L� wURFO iYW 11oNIN WlF EAR WQ0.Yl►E � N" Y 02 00 00 i' 10 22 2012��n 1000 w m RON�EiYYIl/1 14�UfElII.UBFA011L1NFI��IU.E NO�OW�Y011lCIION � ❑ Q [� 0 1� Jackson s w ����� � - - U'T U• Uw�� < r m�artr�a w.�z�a avs�rawr no�ncsrs noure�.z�cco�auwr.oarrwnn� 62 �,`w 3A25 +�. Maryland � ros�nou ara�ac�ru.eu+.� m�� ou�as x�nic roam+ onn�au�nare+.: �uh aw5s aaunuo av, � O1 m663132640115 MN D O1 O1 d004095108804 MN B 01 � r.cronr x��rmr.woo�ua� ahacw�m wwE�rr�s�.�mc.wrl w*cawm. r•cra+z MICHAEL JAMES LEROUX 11 24 67 MELCHOR SRIOSO GOME2 09 29 72 �Q• ORMQ RF8IRKT {R NLiT11GT MMIMER O1 1285 Jessamine Ave W Y. 1646 OLD HUDSOIV RD N.- O1 pryyy p1Y.3ThT6.AO � CRY,S1NtLM PM9CL O1 ST PAUL SS119 6512661100 ST PAUL 55106 6517758�11 O !�Qn� sFa a�mrr aweEan wu�o uFCr iwtn rrx �ccvr ��wr �iow �cr watv awwo "���� M "�}4 "`� 0 4 9 9 ' 0 S N GO�� M N ILLpI iTiE OIiW IYfE TOIq9P TWN9l+01tI MWRAMCl6ENV�CI NUNNJYBH /�L06 M! OnUO nW.. TOM09� fRNlBV00.T MNIkNICEBFItVICE RUM1UMKfl � 98 �� 98 N�: 0� '�, 1�'.` N., o.�,o p onc« OCM OMTIERNYIE� ryE OWNEMN��E fIRE 'OCp1V � Q2 LIEP ANIMAL CONTROL DIV N VASQDEZ EDGAR HERNANDEZ N Q� KM M —°"' _ — . 04 1285 EAST JESSAMINE AVE N.: 12901 COUNTY RD 5 #201 N 03� - � w�ua� cm.:rh.is ativa wicer crtr,su�.a .uuw o+a:cr �enu.v O1 ST PAUL MN 55108 "[a- 03 BURNSVILLE NIN 55339 � 03 w.a�oc w.c uooEa rw� cmn wKe wooa v�w caex woiec 08 FORD VAN 200 RED GMC ENV 00 owasEV nwrei xkee v�eaEO �o��s werww nxG� srnEa r�nnnEa ��or� � ywrww oucav 03 909131 MN 4 O1 � O1 858bvt I�I 12 O1 wwr..+cF wucrmnrtte . ow.w�n.+=a a.�cwrER City of St Paul Texas Insurance w�z�„ �co ixsrec.�o■. .w..w�. ,�o �zw, .nv � � . F ACCWENT W VOLY W A COMM@lGAL MOTOR VEHICIE,BCHOOL BU8�OR HEAD START BUS n^c rvre � R9AEAABER TO NOTIFY TF£STATE PATROL(rpulroA und�r N81l9.783�nC 769.f511�. � � mWFJCJ.�LVErYO.EMM9cal.wraeGWNFRwwE oorw/16En r.nrlFAaLL�fwuwl�ea�x-uoranG�trwE oor�all.e6t I a�aeiurw�n�ca�s wr wh� so� �vne u� �we.a eEer uuatv rorwv m,wyanr '�, . �� 41B4LRVICE itllNMll.liR � . Edqar Vasquez O1 03 2/1�/ M N Do,,,�, 9� o,,; ��� �,,..�� � • pona .�1. i 0� we�awr� mn.a»�ern � I Qorxw � I orn+fltoiob6tGwa�tiEOFnoVCPttNOOFSCfiPi�MOCw�uf.[nMtan0l�rwuanYiu.owt�oMaeF�(il Rv.u�OmrROriflT'illsl.awniaNNatA � I. KCTP � - I � rMRfV�l1�E: 04VKF O 1 �� N77 70 u�a.6• ,`�f O L I 'a�, �F . . .. . . .. . . ncia eiw 03 � Driver of N1 ran into #2 causing minor damage and , i 7�., � . . . .. ��TM ,. � � no injurries. Both cirivers cited, I1 for u � ° ..followinq too close and #2 for No Proof .xnsurance � O 1 I I a ,..._�,�. bN&800E ±. ... . . . MNCi N' ": �� O 1 rweawe Fi; — — _..._ _ ��.,. . . . . �; �; �'r �1 �:{ �`°`w� �� ;rf� 3 wfaT�a, a'- ' ��s }1< _ _ _ _ �_.. O1 ,;;. 4 � ,xE.mrn z �� r r � O 1 os �>:.� � I � I Y;� ��. M6upF �' � � ��• �1 Q 1 1�r. ! I. I I 0 �'; . _ . . . . . . �� � 6d e �'1't � ioaw� �y�. - �� ,k . . . . �. O1 �� :� . O1 a. .. _ orr+m�w.«.h„E.rae.naE. �nc. .�.m.nN p sn��e�ma �orx Ofc David Stokes 655 ��� St Paul PD p a� p o„E„ http://dvslesupport.org/dvsinfo/accide�trecords 2008/Includes_LE/PrintReportIndiv_LE.... 10/23/2012 , __ �_ --- __ ---- _ _ _ _._- .-__ -___ _,s.�...�,.--------r-_._v ______ _cW � � � � � ' ,� ey4 � �.K,s„+ � . . ��,o� �u't; . �� '�. . _ �-� Y �a.���k ��� ^i' � v� �� s ����[ .; �� � � �� � t� � � - fG�3 Serv�G��Qao9e� ' � �'�� ^�' �` ��r ����� �usiam�r, �.� �- �°�a� �'�.�� ° �� bg���.552.774A � ��pirect: � Bpp`►&61A� 130 E ThomPsn 5511 S Ue � V�1 St Paul•N` I �,�,i,abraauto.com a��a ', FaX;651.552• ab�Qauto.com �� GOI(� Er"�.USn•Ag A@ I' � s I I ;3 � I � I ABRA Auto Body &Glass - West St Workfile ID: 26e180b8 FederelID: 41-1942823 Paul Right the First Time...On Time 130 THOMPSON AVE E, West Saint Paul, MN 55118 Phone: (651) 552-7744 FAX: (651) 552-8176 Preliminary Estimate Customer: GOMEZ, MELBOR ]ob Number: Written By:Gaig Scheffler Insured: GOMQ, MELBOR Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: 05 Right Rear Owner: Inspection Location: Insurance Company: GOMEZ,MELBOR ABRA Auto Body&Glass-West St Paul CUSTOMER PAY 120 HYACINTH AVE 130 THOMPSON AVE E ST PAUL,MN 55117 West Saint Paul, MN 55118 (612)775-8441 Evening Repair Facility (651)552-7744 Business VEHICLE Year: 2003 Body Style: 4D UTV VIN: 1GKET16S336105116 Mileage In: 136485 ' Make: GMC Engine: 6-4.2L-FI Ucense: 858BVT Mileage Out: i Model: ENVOY 4X4 SlT XL Producaon Date: 7/2002 State: MN Vehicle Out: Color: SILVER Int: Condition: ]ob#: TRANSMISSION Body Side Moldings Message Center SEATS Automatic Transmission Dual Mirrors RADIO Leather Seats 4 Wheel Drive Privacy Glass AM Radio Bucket Seats Overdrive Console/Storage FM Radio 3rd Row Seat POWER Overhead Console Stereo WHEELS Power Steering CONVENIENCE Search/Seek Aluminum/Alloy Wheels Power Brakes Air Conditioning CD Player PAINT � Power Windows Rear Defogger SAFETY Clear Coat Paint Power Locks Tilt Wheel Mti-Lock Brakes(4) OTHER Power Driver Seat Cruise Control Driver Air Bag Fog Lamps Power Passenger Seat Intermittent Wipers Passenger Air Bag Signal Integrated Mirrors Power Mirrors Keyless Entry 4 Wheel Disc Brakes TRUCK Heated Mirrors Dual Air Condition Communications System Rear Step Bumper Memory Package Rear Window Wiper ROOF Trailering Package ' DECOR Steering Wheel Controls Luggage/Roof Rack Power Trunk/Tailgate 11/2/2012 3:39:16 PM 029893 Page 1 Preliminary Estimate Customer: GOMEZ, MELBOR 7ob Number: Vehide: 2003 GMC ENVOY 4X4 SLT XL 4D UTV 6-4.2L-FI SILVER Line Oper Description Part Number Qty Extended Labor Paint Price; 1 WHEELS Z ** Repl RECOND RT/Rear Wheel,alioy 9595182 1 289.00 m 0.3 type 2 w/o tlnt 3 ROOF 4 R&I RT R&I luggage rack 0.6 5 PILLARS,ROCKER&FLOOR 6 Repl LT Rodcer molding GMC,w/o 15188880 1 436.30 0.4 1.2 Denali front � Add for Clear Coat O Z 8 REAR DOOR 9 R&I RT R&I door assy 1.3 10 Blnd RT Door shell w/long wheel base 12 GMC 11 R&I RT Belt w'strip w/long wheel base 0.3 GMC iZ * R&I RT Side moiding w/long wheel � base,w/o chrome w/o DENALI 13 # Rpr 'Clean&Retape Molding ', 0.3 14 R&I RT Moveable glass GM,w/short 0.5 wheel base tinted 15 * R&I RT Fixed giass GMC,w/long � , wheel base privacy i 16 R&I RT Handie,outside primed �4 , 1� R&I RT R&I trim panel ' 18 QUARTER PANEL 0.6 � 19 Repl RT Quarter panel w/long wheel 15192231 1 545.46 16.5 3.4 base 20 Add for Clear Coat 14 I Zi R&I RT Qtr glass tinted Ind. Z2 # Bind RT Sail 23 LIFT GATE 0.8 Z4 * Repl LKQ lift gate+30% 89025440 1 650.00 0.8 3.1 25 Overlap Major Adj. Panel -0.4 26 Add for Clear Coat 0.5 27 Add for rear wiper 0.4 28 Refn lift gate underside 1.0 29 * R&I License pocket � 30 Repl Nameplate"GMC" 15186371 1 35.74 0.2 31 Repl Nameplate"ENVOY" 15123976 1 42.33 0.2 32 R&I Handle 0.4 ' 33 * R&I Lock � 34 R&I Lift gate glass GM,w/rear 1.0 defoggertinted 35 R&I Wiper arm �Z 11/2/2012 3:39:16 PM 029893 Page 2 Preliminary Estimate Customer: GOMEZ, MELBOR )ob Number: Vehicle: 2003 GMC ENVOY 4X4 SLT XL 4D UTY 6-4.2L-FI SILVER 36 * R&I Wiper motor m � 37 R&I Upper molding oak 0.3 38 R&I Lower trim panel pewter 0.4 39 REAR LAMPS 40 * Repl LKQ RT Tail lamp assy+30% 15131577 1 117.00 j� 41 Repl RT Applique 88937022 1 69.65 0.1 0.5 42 Add for Clear Coat 0.1 43 REAR BUMPER � 0/H rear bumper 1 8 45 ** <> Repl RECOND Bumper cover GMC 12335703 1 380.00 Incl. Z.g 46 Overlap Major Non-Adj. Panel _0 Z 47 * Add for qear Coat 0.5 48 Deduct for Rear Bumper R&I _i Z 49 # Subl '2 Wheel Alignment 1 69.95 X 50 # Repl 'Seam Sealer 1 50.00 X 0.5 51 # Refn 'Car Cover 0.1 52 # Refn 'Corrosion Protection � 0.3 53 # Repl 'Flex Additive/Adhesion Promoter 1 8.50 X 54 # 'Hazardous Waste 1 5.00 X SUBTOTALS 2,698.73 29.0 16.5 ESTIMATE TOTALS I Category Basis Rate Cost$ PartS 2,565.28 Body Lab°r 29•U hrs @ $54.00/hr 1,566.00 Paint Labor 16.5 hrs @ $54.00/hr 891.00 Paint Supplies 16.5 hrs @ $34.00/hr 561.00 Misceilaneous 133.45 Subtotal 5,716J3 , Sales Tax $2,565.28 @ 7.1250% 182.78 Grand Total 5,899.51 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 5,899.51 THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS. "Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to choose a particular vendor." MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUIL7Y OF A CRIME. 11/2/2012 3:39:16 PM 029893 Page 3 Preliminary Estimate Customer: GOMEZ, MELBOR Job Number: Vehicle: 2003 GMC ENVOY 4X4 SLT XL 4D UTV 6-4.2L-FI SILVER Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless othervvise noted all items are derived from the Guide DR1GN02, CCC Data Date 10/17/2012, 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 pouble 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 (N) 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 following 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: j D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category. ; M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories. �I OTHER SYMBOLS AND ABBREVIATIONS: ' Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=Blend. BOR=6oron steel. I 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. RT=Right. SAS=Sandwiched Steel. 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. 31/2/2012 3:39:16 PM 029893 Page 4 Preliminary Estimate Customer: GOMEZ, MELBOR Job Number: Vehicie: 2003 GMC ENVOY 4X4 SLT XL 4D UTV 6-4.2L-FI SILVER ALTERNATE PARTS SUPPLIERS Supplier: Keystone-P+A-Minneapolis Location(s): 3615 MARSHALL STREE7 NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919 Line Description Item# Price 45 RECOND Bumper cover GMC GM1100628R $380.00 I I 11/2/2012 3:39:16 PM 029893 Page 5 �. .,�-�►�.�;y� ,,,�„ .- „�. .,�, ,-�. e � � �.��� �.,� .,,�,�. ��- � _ ° � 6 0 ° s • 0 G ° � � ��r�' VEF�ICLE IDENTI�ICA�ION�,NUM�ER YEAR �' ��MP�KE � ' : WIODEL/BODY ' TIT[��fNUMBEI'�'�,�" ; � ` t „t � ]�C�KE�'fo-16S3�3b���Q57���6 �s�03� � �;. GM� = >ry 4W�" ENV ` � �,,ill7�,'90Zr�'1r2��;��" DATE;IS$UED:�+:k�,� �P��"ODOWIETER - TAXBASE GOD�- ;PLATENUMBER - CENTf2��.�G�F���EUS��NLY� � � !>��::- - r � p �� t`..t� ��' r ' � � i �� ��w ti,,""�r �-'��� : �',u �.'��� z � 03✓,�►C�f1�l� �� �',�„p���324 03312(}� 09 .=858B:UT� � �r^'� � r � � � p .% e �i i . s '��'�ba tlt,Y� f �J TM ��'��k Ay c�r�'�� s t= '�,s�i{°�'� �"3d"p,�ar.� a�"'�E�_'�i x'K�'�k ' . • . " � t�tx�,-�'�'.�,���_� ��""�t* P�`�iw��,�'��'�xt" a - -4�.a V'�- � � :.� � . EXP �1' f2; �.i.�,, � 4�� .�!, ���r� �� _ �� � � � ��� � lK�� , �� ; Q'� . ,w, 3"�;"y� ��y.,� .nA.d',1'd f ?��,. ""��F' 3 %.'� � _ _ �X'j � ' � .. > , ���'R�'����E��'U�}}r�AR�'Y D0B OWNE'R ���� �; 3�� �t �� k ,� � ���,.1:��`i��OF��� �'�'���- ���"> , :21fl8], VASQUEZ ETIGAR .'HE�f� � � � , � '� 5 �, �� n � � y yi++ �- �ft.'�a [ � r �7��,��y.� �' �'�¢' � �'h� ,'�.' �. . .. . . �,�. *' - �n �+3 '� ��'iiY' � 45,� �-f��� sY � h . � 'u' 4 . �c.� ; � ��1' S, . UN��ERSIT ��d�l}'��. :FINANCE` 'LLC " ~ �� k�����, ���� � ��-�3. �> �;��� �S 'e„ ,.��.n�uut�.Y 3x�p��� �� st > � '` � t `� ��� ,��hr �� 4 Ex, w� � � kf"� �� 12'907, �C4tf�iTY R�,M�� �#���� s ���6��s 5-�+- � �- s ��x :L � � '- i a'..�.A�" �, ��:� [� � �° �,� ��� A�fif �:����f:RN�`�fIL�.� TMN 5r����37���2^� �6 ����fr. ��� .• �. I•. ��L�h�.� � ��`€ -�'�` ; ' .� x.'�x�y �5A .-�5 �h r ����+»�4wi��"� gE i�, �J . � i �{y; s�;� s ; s - -` �'. A .. � ..>?I�� -.. o � � �r -t,.'"�r'�'�<A'- �� a*�a F^' n '�`: { rnc� f "'3.' �� �� .-t �S�' '*.� .s>� � �.ry } ��`�e � '5��+���1�'. �. k..� y� �W,� � ii�ii��i�u«��ii���a���i�a��� ii��F � ' �iii��ui����iuiiiu���i��'���uii� � � T�� . . � �.���: ��. ..� � , � � , -� �.� �� �� ��h.. ' �3i s{ � +y"f1 .� Y V � L �� ,: a ,� � 3- ,�� gni� �.��r e,>� u a n �- �^ � .a ^� �d„r � � S- ' ' �.'�fr ^���d`� t � �s ���-w-* '' 's Y .� _ 3jtl �" � �°' � �� � � �x����. a �jr ����}� ��. ��,����:. ." 3 , ry"� : .� �-�,Y ��,n��.�`".;�� �,.� _ �''� -; y � r x ' -" �-c ,- l ' �r 3,�� ��'S3,rz .. : 'x nn�l�ar,.g.� iN�N�S�%,�`,`�:��PI"4��'u..�ar,,.�s;..4,�icx,`�„�:..���'<..[ .. .�%"+. ,'; `c�s,'a'.;-�^'^�`'r ,.i'..Y . - ���x "✓Yi ��{ r �"� x }+ { , .,r.•+: .. ,..�>_ f ,.s;.: . , :c� 3 �'"�„ � �. ,r.'�'�f� � , `'i,:m:e�+✓" 'a+73 �"�-'�, - i4 i . <` �.� u" .�,x.,�' '14 � 4 I'• i .� F . „j .... . ..� �+6 ra` 5':�; ` EDE �¢1N��.�7iAT;�,��V 5 r i Eii����,1•iY�I�ST'/lt�Tl-�ENItLE/�7a`�11J��NI�IEC'XICI�dL�(l�'�`H,T�IE7�SFER�3FQWNERSHIP.'MIWNESr,OT��(�3 �` h ��� � � ��� � , � . .. : ,.. . . . . , � � �°, '��►�° t ��"���,, ` D15CCOSU12E�i � �`, �., �NE t�i1CLE�'A FqL3E OR FRAl7dkFLEN7S�aAT�M�lVI t�F�P� �BYAt1 I�ERSON.IS A Gf2b5$M��E' ..... acc�4d"��� �" `�� I +4g�rr a114S F i, ry,��'�' 4 a r� '�' ,`_ 3 ' ' � .,h� �y ��,;�� t � - � - ODOME R:U��ISu��.d�U�� 7s� E�,'T.�.��V��j��E��L1FY71iAT�HEODOME7ER'N�� ��,��,.. -`,ACTLCAL�NjL�RG�'s- � "`' ::��^ ^��'� "�` �.:..,;�� �..:�..� *,t�+'�*�,�,�"qj�..•��� .��,��.. � r:,-'' � �m x�,. .. 7-�.�'.�,� f��.��„ .,.,, , ` tn..:•>?r. �, y t . ` `� � , .,A' v. �"� �bv> k� ,:� . �,.READS•.:�?...o - ?'s " (Kl'C���WSj kJIILES ANb TOTHE BEST�F MY K� ��XC£�l��ECHAIWCAL L1F11YS OFOA(S�l�i��;�...#;- -:� �� ��f��������' . .'KIJOWLED�E;TFiE ODOJv1ETEF3 A+1ILEAGE ���,:x � � - �,�` p° �1��NG�ACTtIAL K4ILEAGE�:.-WARNING�OdOIY��E��bl�R_P` „�£ . ``.�"�i a������,����-�� ... : .: . '�. "� -. � �. ,�^;_ ': �: �T a -'� �'- - .x'z$ f._.,�„ a,�,,:, 7)AM/�6EsDIS�LOSU[��i,SbY T�IY� , FOx�',(��sB�SY OFy�uIY KNOWLE�GE 7FJI3 VEH � ;;.��iq$ ,�t, IJOT{CFi�CICONE)SU57����0 D� �� � $]' . �.��: REPLAC��OR 7�6�$tpii�A�F� #�-S�F�fy�)�,fi�Fa CdMP(�NE�lTSTHAT WE,RE R�ALA ED b��'ff�.T�EPL6�'MENY CSF AIR��AGS iN EJCC�$5�:�F?E � �L �k{, �"��y.� � '�. ✓= � u .�.u� �� . . � : ,. � ,- ti f �s�P i ,�'r�'-� ' �; ���,; . � t :;Jc�Sf�NME�J�''T�Y,E�CEk��'�FY T T�'�F��ifl�UEHIClE 1$.FREE FROM/�LL SEG41f71'�IN7ERESTS 1NA�RANT TISL�ANDr�S IG. p " t �r„ � $` S� �� '-.( G 0..Y-�Y" J y y�.i �� .,�. �. �° - .,,r+2 � �� ��,f`��'r . �- � � {� �'�-� �', ..���� ,,�m s.� � ..���r � �. -_ .�y�°. ��'��. . � , fw� x�'� F,kLE{� P I �b 5 ,' ��OF SAL�` '� �y � �: � .+�,� �z'x .� { � r �6��'ffER,S S a a�, ; ;' c.x � 4 . t'�a'��'� ,�9 z ..�f , ; . h 3 W#' l �y ,� - ��z.��s°��3� ,✓ � �k.s �s�4'"'.� _ '4 � 1 �.. ` '' �, a r:°r c. SEL E �DQRESS b ER S 410ENSE � ; g •�- �w s 4 a{ � � � t��r3 1 �z v. � ��RS N �. 4 �3�����, r �� , J\ m� � t`�� .�: �t ; y S S �URfi� . `� � ,�: . �,y.z.�* s �-'+di�e���� sr�,d.�k K„ u-.,�y .r��+y , . �. �.1 p,�,� � 4�_� ��. ���PP��:�l^^ N �"�`1��S��BUYER tRl4f�1'5��,#��`� �NitIS`� $E �UBMITTEC3 1 ��C�. � � � ;� �7/� �`�,f ,,�s�2r�i.�' {��`�j ��`. � ' f :s 3,.' t ,✓� 4aa ¢ ,�* � u; .q� S, � ��,����.�t: '� �UYEk3F��Y�'-� � '� ��/ �� �� : �� � ���,;� �� `��� p �' {A * � fi .�k�i�*"�� I P . � . dA oKwfxrt� eifYe $n[�vERSti :� '�,�� �x II �` � a' ��� r � '�y� zt���ya'.. � w� r�ayw .,u�r��� � .'- ` E �!�,�� �`z, �� �, ,�`&� �'a ?' . ; � ��g�lZ'f„ � ' � �'�`o. '� t��- �� .ADOLBIlYER5FUM1IES ' LA§ ,�• lJ' ,� ' .; � - '°5� "� =� � � r�pfr",�S . � no6e �: �. � .na� c.��n� eur�a'i �s P �' r v . j �'.r- i l4 A �,.dl it�(Y ;_ �� ,� �t t7.� �ilr1F a�;� i �' .. � �� � �. $f ��s` .`r°��ss.�k �S '�-,��'�4 E -��'� � �-e+rK:„ ]P(}� i �1_ � �$r - � - � � si�er"�nt�brtESS;;�lF 1� �a� i� a�i;.�.� ,��.� 4F. �i.��';-z,� ,>„ ��'� �r �+� e; � } ��r -*: s�'"^"t �y' y�'�'� ��" . „- .,... -,'�I�' - s .� � s.� -� ,,.eotiNttJCOne:: � ,T � .�. � � � �o ��h�: � � "�STF���k��EF�F�i�E S°� �� _ `�" ��il'fY,i�`l��tEEli�EiJT S)�i'- 1?�,<<:� �- L���S(�,FYES''�C]MPL�7E�EG7a0.1?1 B� �31�f ° ��� n .. F a�� r'�,��"rt�'"�' " � �- ��` � i `ti'�N�i ���4+� �Im��' ��.dd� r `�'xs'��-� r �`� 5�4 -, ."s,. '��,� . �� q�� , � � p�"x r'�'� Ra� b, s '�� ,r C"Y� NN i r'�' ���.� ri�h �_� rl"�r��,.'� �h,-��,.�"� �� ? '✓ ...�.�_�'a '�c "c�,��� . � �' �.. ���.4.'� FirisrsECUgEn�,�h�'+'swuE �y� '� � �r , �inr�oFSEC�art�kca�idlSt�x � � �., ri�d�aN y � a��u3�ii7-o3v- £A��`�'�;,.� " ` k+ .� .: � t=. J.,"` x . T' -'t!" L Y, {, 3' Sf Ur�"1,'w� �'r.' . �E'+ f' `fi-'E t�'S �....y..,�9� �". '��S � �.�� :�,...s° , ':��, �" r _ rk N.�:t* �h ,W4',�� x�'°�',������ . ,. s���oonESS z � ' ` � z �- �a�r � ` S r � FQ , .�5„ �.� :1(N!@)C�RT'IEYI� IAREY.�.�,�L,E�SFIkJtG.Fx �*��F EQTHI,$VEHICLESU�J�G'f?,{OLI6NSSHSJ�¢NDNQATk1ER�i(V�E)ATTES76YtHiSTRAP� ION A li1S`�M.� Y Ep � r 'VJH�LE'QPEWtT �' NYFI� 41L�`�EEt ��IGHIN ALCbFMY(OUk}pECL/cRnTIGi�SARE�a'I'+4�RbG.CyARR�G�'SE � �'�� a� � �`��� �� � ��:�� r� �y����P�,� ��: y �� 4�,�� a'� ,� g x �r�yk ���' �'�� R ��. k� �+ � � .� .� . Tkro"�� 'z �.� � � .�� �� � x " .fu'."" _.. r', '��;� . F�,,. . , " ., x.,,. �A� I��1��'�S/L��7?�'� � '�R��(S�A.I(Mus#SigR , M� �3��^��.��fa�-� � .� kt � ; . � .. �. . .,. y.��� : w��� e�eeno t�� � ��S R �ne��pvucnncar+unECuh��rxnw'�lo�i��`�tl JIY�N#t�lHCirbh + v FNwr�E�6aRrnnn�` utna�mu�opnert�nuEStEOnGt�a+a�:�"%cr�T�KC�2�{t�SES �QFEOEni�H m�: �.nMD.srA7EUw��rERSONaL�{jFbRkuj�a+$,bNfNr�Ee.IjA�raRi�L�p�.�CATwtar.ylrrateEO�9a.{��orduryblJE+yfiH(�tkFY EkPnES3`c6NSet+ss�ouAUSw �,�.- � •r � � �J � � u I� ��D(PRESSIYCQNSFENfiT6'fF1E.015b`40SUR@O�VOpR�iNpORMA7iON81`WRITIN(3dT071{EFdLLE�RiNGT�iDfiftSS: Y"� �.'� y�a3.�E A �', I 111 1' IvjINIr�S�Tfi b pART;��SF El79Ll�S/1�E1`S� �e , � 1 ' � I 1 I 4 � s �. �RI�ERA}+� f 311�.ES�[�jS1�►S�1�N� �r � 445 MINN�$OTI���'f3E �'a���r�~�1�NK�r a�S�Ai; � � � � �� � � PHOh1E 651 i!9� T�� _��������,t` " 1 1 � 1 � I IIIIIIII II'll III IIIII IIIII I�III IIII II�I '.`:�� � d�y�{� .�.�,x�' �� �tF c���`. � 5 f ' 1 1 1 � I1 7 1 �. F j� � �'' r�.�a�"�'.v a ��3'.; } � P PS2700-17 = tk��,�������} �"a����,� ���� � , �� � ��;:�� � e � � 1 1 � 1 1 1 � 1 0 0 ° ° 1 ° 0 D :�. _. _ � . . , ;,. . . �� �� � � ' `' " °� �l1INNETOTA M"OTO(i V�HICLE��REGISTRATION: ' SELLER'S NOT,�CE OF SALE ., � YR nK na� � viN � , ` , ... 1Mien you selbthis vehicle,you are responaibfe to file the fnformation on the back side of this oodce with the 0 3 6 N C 4 W £N V 1 G K E T�6 T 3363 d 5316 Department of Public Safety wifhTa 10 davs.please file this infortnation over the firteroef at nlndrlveinfo.om. �;, PL ATE. �' S 7I C KER = TA X EXP ` ' call 651-2841234,or complete all the fnfo[mation on this notlee and mail to the addreas below.This notfce ts noE 85 8 B V T - �K'38 376 U 0 . 33l�.U 0 11/30/10 � requiredifsoMtoalicenseddealer.Mtnnesotastatute168A.10 'GROSS VEH�CL�:`:WEI�NT/BASE VALUE' 033120 : ,'�MINNESOTA DEPARTMENT OF PUBLIC SAFETY ��RECORDED OWNER(�.S)`. ' �. - � � . .- '> ` ,�.,. : ., . � ,_ pwveRnN�veHic�eseRVicesoiv�s�oN ;', VASQUEZ EDGAR HERNANDEZ' ,, � ' '�'. , . � 4d5 MINNESOTA STREET,ST.PAUL,MINNESOTA 551015168 �°� �..:"� „ , . ' ;.,� .� `� � � :� � .. �� ., . _.�- _�.� . . .. '. . � „ � r� . .. ` �, ; _ � . .�., ':.�. ', _ � ` � . . : . ,: . ����������������������������� � �� � � 1Z901 COUNTY''RD 5 #201 � ?2�L� NUMBER Ji]6�IOZ912 � � VIN�� �IGKET16S336105116�� - 'BURNSV�ILLE _HN 5�337-2234 � � , � _,j; � � � � � CONTROL FEDERAL AND STATE LAWS REQUIRE THAT YCc�J STAFE TI'E MILEAGE IN C�N(�JECTION WITH THE TRANSFER OF OWNERSHIP.MINNESOTA NUMBER � LAW REQUIRES.THAT YOU MAKEA DISCLOSURE ABOUT DAMAGE TO THE VEId1CLE. A FALSE OR FRAUDU6ENT STATEMENT OF PURCHASE BY ANY PERSQN IS A GROSS MISDEMEANOR OR FELONY. Sl SALES TAX DECLARATION AND FEES ' FULL PURCHASE PRICE................................. $ � , _ REGISTRATION TAX $ j� (�� 4 ................... _� > � � �\ PLATE FEE LESS TRADE-IN ALLOWANCE.......................................... ARREARS TAX NET PURCHASE PRICE...................................................... %OF NET PURCHASE PRICE...................... LESS TAX PAID TO ANOTHER STATE............................. � ��' � NET SALES TAX DUE $ PSV FEE � , rj ' - _ TRANSFERTAX (..Q (3a TRADE-IN WAS A: TITLE/TRANSFER FEE � �S MODEL MAKE PLATE OR VEHICLE IDENTIFICATION NUMBER SALES TAX YEAR Minnesota Dealers License Number: LATE TR,4NSF L I DECLARE Minnesota Sales Tax Account Number. � S TAL $ "'7 S THIS TAX EXEMPTION Intemal Revenue Code Number(IRC): STAT DEPUTY I E Q CODE: IRPAcct.Number: _ __ � -__.._ .. ,. T $ � b 7S If Leased,Lessee MCDP Number: � /' ` R E A S S I G N M E N T B Y L I C E N S E D D E A L E R O N L Y :I(WE)CERTIFY THAT THIS VEHICLE IS FREE FROM ALL SECURITY INTERESTS, WARRANT TITLE,AND ASSIGN THE REGISTRAT�ON TAX AND VEHICLE TO(BUYER): ODOMETER DISCLOSURE STATEMENT. I(WE)CERTIFY THAT THE ODOMETER NOW ❑lSACTUAL MILEAGE READS (NO TENTHS)MILES AND TO THE BEST OF MY ❑�CEEDS MECHANICAL LIMITS OF ODOMETER KNOWLEDGE THE ODOMETER MILEAGE: ❑IS NOTACTUAL MILEAGE-WARNING ODOMETER DISCREPANCY DAMAGE DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE,THIS VEHICLE: ❑HAS ❑HAS NOT(CHECK ONE)SUSI'AINED DAMAGE,EXCLUSIVE OF ANY COSTS TO REPAIR,REPLACE,OR REINSTALL AIR BAGS AND OTHER COMPONENTS THAT WERE REPLACED DUE TO DEPLOYMENT OF AIR BAGS,IN EXCESS OF 70 PERCENT ACTUAL CASH VALUE. � � SELLER�S PRINTED NAME(S� DATE OF SALE BUYER�S PRINTED NAME(S� . � , �. ' • . . �- . . . . . _.. . . .. `.,�._,_. -�_:_-__,._. .......__....-_. . . ._� . .. . .. __ _�-� _�—' - ._. . . . . SELLER�S ADDRESS , � � DEALER�S LICENSE# BUYER'S ADDRESS � � X X II SELLER�S SIGNATURE(S) BUYER�S SIGNATURE(S) '�. ODOMETER DISCLOSURE STATEMENT. I(WE)CERTIFY THAT THE ODOMETER NOW ❑IS ACTUAL MILEAGE ' READS (NO TENTHS)MILES AND TO THE BEST OF MY ❑�CEEDS MECHANICAL L/MITS OF ODOMETER KNOWLEDGE THE ODOMETER MILEAGE: ❑IS NOTACTUAL MILEAGE-WARNING ODOMETER DISCREPANCY I DAMAGE DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE,THIS VEHICIE: �� j ❑HAS ❑HAS NOT(CHECK ONE)SUSTAINED DAMAGE,EXCLUSIVE OF ANY COSTS TO REPAIR,REPLACE,OR REINSTALL AIR BAGS AND OTHER C COMPONENTS THAT WERE REPLACED DUE TO DEPLOYMENT OF AIR BAGS,IN EXCESS OF 70 PERCENT ACTUAL CASH VALUE. , �� �� � SELLER�S PRINTED NAME(S) �"� � � � - DATE OF�SALE � - BUYER�S PRINTED NAME(S) � � � SELLER�S ADDRESS DEALER�S LICENSE# BUYER�S ADDRESS X X SELLER�S SIGNATURE(S� � BUYER�S SIGNATURE(S� IMPORTANT-PLEASE READ: ALL INFORMATION COLLECTED ON A MOTOR VEHICLE APPLICATION IS MINNESOTA DEPARTMENT OF PUBLIC SAFETY REQUIRED BY LAW AND IS ISSUED TO IDENTIFY YOUR MOTOR VEHICLE.FAILURE TO PROVIDE REQUIRED DRIVER AND V2HICLE SERVICES DIVISION INFORMATION MAY RESULT IN DENIAL OF THE REQUESTED ACTION.EXCEPT FOR CERTAIN USES 445 MINNESOTA STREET,ST.PAUL,MINNESOTA 55101 PERMITTED BY FEDERAL AND STATE LAWS,PERSONAL INFORMATION CONTAINED IN YOUR APPLICATION PHONE 651-297-2126 TTY 651-282-6555 MAY NOT BE DISCLOSED TO ANYONE WITHOUT YOUR EXPRESS CONSENT.YOU MAY EXPRESSLY CONSENT TO THE DISCLOSURE OF YOUR INFORMATION BY WRITING TO THE FOLLOWING ADDRESS: mndriveinfo.ora SELLER'S NOTICE OF SALE FO� YOUR Pi;�T�CTl01�! � Date uf Sale Purchaser's Udver Licsnse Num6er . . UPON THE SALE OF A VEHICLE TO A PRIVATE PARTY, WE RECOMNIEND THAT THE SELLER AND BUYER TAKE TH� COMPLETED TRANSFER P"""�°rSF"""a'"° 70 A DEPUTY REGISTRAR. �. Street Address - � � � Clty County State Zip Code . ;% r„�"'��,�#^"a,,���,�.,,a °�� d Q a�- - ` � e'�'ud'�"�a�- ��.,�►--� ,. .�n���i •� • �' �� u � o � D � � � �� ��. � - o 0 0 0 ;: . .. r: 3 i_ �: _ .� �. 1 �... � � .. _ r.�. � .. � . ,�f�x �ICLE(D NTI IC � IQ1�1 UMB��R EAR '`,.� M1hAIZ6�"'� r MC�DEL/BODYr F �£ r�T,TL�' UMBE�' u�� '`�,�"�°�,; ,,� �� -�: �``�_ x�a TYr'F"�v ..�, �� Y a� y�tG „�,�.. �c }?. '(" +,� :��t�.:;. �t9^. -r�+r 5 � 7���K�fi�16 S`��� J 5;�b�,6 ,��� �;03 � ;� � G C[ °r '�.�� �� .�: �4.W�� E:N V `x� �"�4` �-�'������,�r2�'��4 �_��y,,r ` .- D�4,F�1S30ED . OGYOMET�R =. � r TAX;BASE ,,;'s n CODF�"�-? PLF�TENUMBER.. .�,�� �,�ENf �FF.�C�US tY � ��i� �� r Q��'��'��"�1` R'` �} r�32�f�xr �` ��#3�,2��` � 09���:.8�$9V�'��,�.�� '����� � ;r�'� �{*.� r -�.w r-r�. �^" j �� a+,'��`.� �`,�"`�-r-,y�+i, _ � y:.�Y�a .. _ . ... '. " S�'��,�'.��, 3` '. � ;F._ "'x�;E `P<'� _ � ��. .`}.�.. �lt.q,. `�,�. rF'�'��' h �j t t`} F��N �.,;tf � M r��'1�� . �� �� K'r�a ni ,�Yt-��.g s-��� .� ,:, = E�X P J!�!. ��`�„ �°y �r[" «.,s�,,..- a� � ,�,�. 7 t._ - : ..,.;<.� .:. - �� . �,�,:� ;-r� e�;. . ..�.k'- -�. ��- '_ ..'�� . - . ��:.,-r P���� �': �t na��� `., �s; . ' .,. . r.s�'� s��� '. : ... �,,,rc ..,, _ ��}.�.�� - . � � , ... . _ � �r>� .aa 1 i�, -.d'�. . c.,;F,.c� � :.� ..:k�. _.-': . �;'F 1 ..yl , :.�_r�:c3,ks�� �.- ��45� �}��: __ � ty � 5 � �a T .�_.� �': f� A�R'�Y . ��� :D 0 B ,. ° 0 W N E R ; ���: �, ��� �'�G�. < ,.v � ��,� .� . - < � ,. ,� � �--��, � ., �,��-�.y' -.� �.� �� �,; �,. :,��,,� �ti ` 23,flj8�, � � VASQUEZ E�UAf��IH� - � ,� ���� $._. .���,.�}'-^ s"'�_,..��'��.¢.�s�'z� ,_. � � �� ^ � y . " t,r.�.k�n..,a„�, b-c�rkr�e-�._ ���' "�� r u.�� '���. � +4N. ,��� ���iNA�:I\�L�������''�°2� . - �: 5��,��' s���r �-.:� v � �� . � '� - z t.�+- u � F '� �`�� ��. E��� x.�� 12901����'�Y�t3��� > �. �4 4 ~ �� -� > � - ���� � -�,� s � , � .�;�v .� � �'� °.� ���;��� � ���3�2f���ll�,���'l��S; _ �.� �� ��•�� ��+ ,��`�a�� � � :�.� ,t���,,"��',���-� _5,YS rst y�aB- ..."u. ������.".��.. � _,k�s-f7�*"-'i -y^ �1"j{q�1{Y �"`PS�-�f"� \ s �i . �'' '<..' �� �.�� -�..�,�""�� .. ���� _., �li.I�� '$3" s� � ��� . 1[1�11�[ll[� I�1�111(1�I � � �011ll � � ` ll� l�' :t � ��t��. �. �a+rc' *<."t� ,��r�'�`'�'�'^��" � �"tM u ���,t�u'`,'�` �������� -::br � _ r� � � �-�f�� �g,,,x ` -��``�-�,-'�_t � *` � _ '�'� �-�`r��' ,��.?-.:s �'=z � z�- �a��yy�x`���`-��^sY�a''+' .�.v:_� . �N' .�tra�.�^� ��.'*�.. .��,. � A?4:...:.., re.:. �4. s s.+i� .''�?tat.n�-:.�.'FaS. ..¢, s:d a'tst -zz �.. ., a �� � ar'�`��,i��^�fi��n�i:�eat�"` _ �°���€�°`� a�����H�� , : ., N I.CL�r�Ff�L�u�k�R FF;f1C1[��EN7' �,E' �'+��!' � ��/st4 P�F�Sb q Glz �� M $- E TFI�T'if�E O�M�I� .O s � � .:.��1,4 �Lbt . -� . '�`��7 � . ,�, `! a�„'sc�.���"' . r � i ie� iKr� *'� +si'2 `� - t;� � � T _ e+s �t-�,��to-rti�eES�pf m�x �� ,� "����o��a6 �� ��O1�L� �DO' _ ,,., y -s A .�, �, � :�`'a� s;c',ar � , � ,a'�.z"'�L'�� taE�-WA�RNI�IZi.i�Qb �cFi1 �� .V.- �� r�u�a .:� �� ,: - u� s. �� &�'� ...sEg F�3..r'f�S 1T y` .,},,. ��+ c"�"�zis��asu€�� � y s� �'�pt�r isnrbw��oc �'Ki��f� �� .� _ . �'��s� �T� - r�J,�f'csr��trr� ; �iv�t€���r��c`��ti��„c���;� �a^�+�.��5�Fr�_ . � �-- � ��. +�� �-�.�,� r�. �° � � � "������'� -r ; I'��'1✓EHtCL�l$.FFtEE F�2CSM}lC�..S I 1fJ..• �S'l'�'� �F� Z��JCN „ ���� - x � ,� �� — Y ��#� � � , ,� � ��- ,� � � ,,� ,�� � �� - • .. Yb x i ����,� f � ��„��t '2e"i'"wF r,r`.� �.� �. � L 5�.y - �4z"' .wy� ��.:"�C1 T��SAC����.�-�:�"�' c'� . .��. _ '♦ R A 4 � 5, ��-a .9 p�`"� _�` ".c._-_ a��r y'= _� -� w��,.�a. ���M#"�$:% "r-s w"t`�; �`�'�:� �..: .z �� .. � �,���"'S�'�r �- -5"&� . �fx �CI�ESSta �..� �: �,g�„��°"�^ cs,_�1� EF�Sfi�,���is. ,eh-��,-rr�... �'� ,� - -�i+ �:.�� .�, � J �5 �.. ; � .: .. s a.. �����n-�� '"'s�a� ""�"t'�' £�l€�'+.�� .:.i� 4'�` ?I? �, � . . ��' a't �� �,., 'r q c�� ;� � �`� : � � � , .� . :� ��` `""�'� � �Y E R% p �b ��ry.-s-�' py -� � ' ��\A- � .� �P �.: D�� �G'� 4 7 7 � �h � � � � ' �-` �/� Y ' s� �� �'- ���,q������'_`�p.'� N ;�� �- i 1�1 �""��t's'�3�4s3" R���sxC+�. Y.. �` + � . -" xk����'> +z �� ;:� r.x.� -� � '; � �t'�� o'� t' '' '"'r`��,� i .T �� i���:s"_x+. ,,.� :.b�?.� �`��. u+i'x������§v.�4�¢a Ei.�'�e'� � �� � + . � '�� dtxSE�s ���. . � � x` . ....:� .-�:,: .�-�.i 6N� 3"°'d ,y '!- '� a qft"+�� r�� . '�. � � - :.�.. t �eiR,. -... ... __ . � . �. ' a ete . '`. � �r»�...."6 '.� .�. " �.. ��� �. -: �� .. . �. .. ,.- .�_;,. . . ; 4 � s ���� , , _ ���r s�"" w-.,. . ' ��, ii�� �' � .`�.°..�,``�,,:;s �.� - �,' � - . .. _ . _ ` ���' i . , �. `i����EE�F�V�ZSj��` � � i,���"Y luip.�Y�S��i � 9� ����- �r �, ,z ���� , "�'i �'��''�`� �,_ �'��� �#, � ��" ! .F�srs rY� a, ' �..�,� �r� r �� � � "' � ��"�'Wi�.�S�`Unti�'' _ I � � -��:,` { r �- ��« -�. ":i�1 F Y �`!.„-�3r ��� aS.'�-�v�":''''"�'yr�c��`"'�z;�s� y,. i �4 au'} �S .JS�"'�+'�._�.a�Y''t£ '�S � � f�'x"� t� -.V Ti�PeRi h-T F,�,�. a. t v (�, ,es '5�'�c�4 �. � .rY ., `�^ -�'-�, � �`�''�r`��`',��'�s'�r� c'� � � �°�•.- ,.� rt .'1.:� G�".,..�-r�..� c � - .'� -�. .� .�, r LM�. C � � �,�� . .- :- �p�� ��Hie���su�r���yt� s 'ar�t 5 z�'e�a;�wis ��:rc� . - t� �Et. r���i � i n��c��a�V����w� tu��+C���`�--`�-'-,��.^� �i'.., � . ., . ',.. � � " .?� -. �� L i}, , .. _� - `� � .. � _ . .i- .. �� .. . .�. �r,.� ._ �f ,�+r '. �.: ... x as � �.,� �¢�� :. � �: � „ � r- �- 'a °.N: >, 'a's a �c.;:v ,&�*..xxa:'.k,s �.,.,: „"j,1w3.LT'� .", t �_ ,-�`'°.;r �m�.-t=� ,^'?'N',R y ...Y .-^ tt .. �� p i�sn�rr, j ���,fN,M��Sfi.�l��'��'� � n#,. ; , , � . r�1en'n6s?' a'� 3 �;� � . .. FY�+fi ttff HeCtAESiEf+�� �R6� �'^�SL'Y��ON��ENT"YO�fI..-� � ��H � 'fIOHBV'd/Etl71�i[S��h�ti��r .;�. _ s � ' � 1 �� � �� 67 � 1 y't{'��'`�T �'R` '! � { � { � • � ���� } i f 5� � �-�t45 Mtx11��G ll�i T � I��III'II((III I I�III II III II IIIII II)I IIII �iah��P �'iC�E .} � 1 1 1 1 � t 1 1 � � ��� � + � ; �+�'y �f .xK"���x, . -�� � ��> � .�i. .�: � PS2700-17 �. ,,y����1��`` � '." { + + �. ' 1 1 � l � � � 1 p e ° ° � • 9 D .. ,. . . ; . ,. _. _ �� , . , ._.> . ,..:., � � � � .::� -. t,�y�?*' il"�-�s _� �ss ncq?,,,w y x � >— ' , 1 ; TIINNESOTA �OTOR VEF�IGLE RE6ISTRATION ` 'SEi�LER'S N07'CE OF SALE , - � � ' � - J. , s YR NK� - 11DL t^ VEN a WFien you sell this vehicl�,you are rea,ponsible to fiie the infomiatfon on the back auip o�th�s fiaUce w7tK,fhe ➢3 G n C ;-"4 id :E N V - 1 G K E T�16 T 3�f�3 0 5316� DepaftmentofPublicSaf�jrw/thiri''/�Q�'avs".PleasefilethisinformationovertFiefnf�nefat�nd[tveinfo:orQ ,, ,4;� Y FLATE •.= S71CKER 's. TA'X_ ,E3�P ` ' ` - ca11551•284-1234 orcomplete`alithei�omiationbnthisnoticeandmailtotheaddressbelotiv:Th�aaotisefshof vt: _:8�8BVT:Y � K��b37�00 13�;:00 �°: 11/30�1U - required if soldto e hcensed dealer 1Nihnesbta statute 168A.10 � { � '6ROSS tlEHZtL� WEI&NT/BASE VALUE 0333Z0 HIINNESOTADEPARTMENTOFPUBUCSAFETY k ����� 3"pY"'-'}`r�3 E {`� ; RECORDED�'dL1N�Ef�(:S)< ��:�' �r t ��� z -�: r `"}�w ;' +pRNERANDVEHICLESERVICESDIVISIOR '� � ' VASQIIEZ� �D�11R HER�IANDEZ -.� - �.,_��d5 MIMa�SbTA STREET,ST.PAUL;MINNESOTA 551015�,']6� . �k� - ir . Y '� f j_ ' �1q11U(�I�IAll�lll�UlNA���� ` -`�� ' 12q03 �t0UN1'Y�RD 5 4201 TT'FL� NUMBElt J06gaL4f2_ � :' VIN 1GKET16S3�6105136�-;, > ' _<<,, , _•BURNSVILLE 17N; 55�37: Z234.- . - 1 �iiisirrri�rirrririririsioiriwrriiiiisi�rsirir�ririi�siiiiiiiiiiiriiiii�iriii�riiiiiiriiiiiriiiiiririiiririrrrrrrriririri�ii�rroioirr✓ � ��� / � � ��p ���- STATE OF MINNESOTA ` I ':i'�tLio �,.� � � . . i CERTIFICATE OF LIEN RELEASE � ' � _ TO A MOTOR VEHlCLE � � � � ���j���� � � i � This security int st is hereby released on �b��Z—f Z-- � � Date � , s o i � fig a e of Authorized Agent " e � ;f � � % _, � � IMPORTANT DO NOT DESTRDY � P � ; A��p�e � This Certificate of Lien Re/ease must be attached to the pCT 2 3�012 � original Certificate of Title to establish clear ownership. � � �ePutyn40 Cs�w�s���,I/w/.r��I���,/�,I�,.�/,��,I�.r�s/I�.i I/.r�.I�r�/�.I�,.������w�.��./�.►�.��.��.I�s�A r�����.I���.►�.1 r�.I�I'�w�.����.w�����������.����.��,,��.��w�.I�w�.������.��.��r`f Minnesota Department of Public Safety Driver and Vehicle Services - Pre-Sorted , 445 Minnesota St, St Paul, MN 55101 First-Class Mail v Web: www.mndriveinfo.org Phone: 651.297.2126 U.S.POSTAGE ', TTY for hearing impaired customers: 651.282.6555 PAID Permit No. 171 I Saint Paul,MN �� Certificate of Lien Perfection PS2701-08 Retain thls doCUment— See reverse side of this form for removing this lien. Plate No. Make TiHe,No. �N 8�� �pqC 70690Z�i2 1GKET1fiS336105116 Mo�lef Yr Model �tY a� 03 4WEN 12/19/09 �N HaLDER � f I �`;� ' iST SECUREQ PARTY ,f: ���:� VASQIId EDGAR�'�,EERNANDEZ,., �_�.....�r___ ! i i2901 COLW�I�YRDS#201 �1�1�11�1'1111��"III'III�U'�1/1�11/1�1'1'fU1'1111�1'1�'1111 B(IR�TSVI[1.E MN 55339 T2 P1 *********AUTO**3-DIGIT 551 UNNERSITY AUTO FINANCE LLC , 74�R4BE�T�3 SAINT PAUL MN 55107-3226 � . , , . Sales Tax Affidavit (Declaration) For Gift of A Vehicle � � �DU3 ��C . Year and Make of Vehicie �� 5� � �T y � � Plate Number or VW (Vehicle Identification Number) I (we) and Seller's Name(s)—please print I (we) � % �OGt/t� 4'�`��� certify , Buyer's Name(s)=please print That the above-described vehicle was a gift between the above named individuals. We further certify that the transfer was for no monetary or other consideration or expectation of consideration. We understand that the preparing, completing, or submitting a false or fraudulent motor vehicle sales tax declaration is a pross misdemeanor; or if the tax involved exceeds $300.00 a felony. X 1/ � � _ Seller's gnature(s)—all sellers mus sign � pAI�� e Signed and ste ��� ^ ' , me n` �fJ'� - /v� (date). �� 1JQ X;- ,%; �� OCT 232012 y a ure ��'� Deputy 140 County State M Commission ex ires Nota or De ut Stam X Buyer's Signature(s)—al1 buyers must sign Signed and atte ted ��. n 8� Befor n — " � � (date). ZIpZ �Z 1�0 ot ry or ign e Count State M Commission ex ires No'f������SCam . Please note: If purchaser has a security agreement (lien) on the vehicle a signed explanation is required. The transfer may be subject to sales tax. PS2080-04 � � � ` .