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
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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
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11/2/2012 3:39:16 PM 029893 Page 5
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�� �� � � ' `' " °� �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 �°� �..:"� „ , . ' ;.,� .� `� � � :�
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����������������������������� � �� � � 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 .
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' , 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.-
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� ��p ���- STATE OF MINNESOTA `
I ':i'�tLio �,.� � � . .
i CERTIFICATE OF LIEN RELEASE � '
� _ TO A MOTOR VEHlCLE � �
� � ���j���� �
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� This security int st is hereby released on �b��Z—f Z-- �
�
Date �
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fig a e of Authorized Agent " e �
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� IMPORTANT DO NOT DESTRDY � P �
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� 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
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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
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