Schneider ��r���� ��' ��r=��I�� �'��1� �o ��� ��t�T �� ����t �'����, I������e��#�
6/in�tesota S�nte Srn�ute 466.0�slcr�es that " _.zi�e�y pc-r.ron...rvho c/ninis dnntao es fi•oni mz>>murricrpalr[��...shnl!cause!o be�resenlec(to 1he
QOV21'l1l17°boc(n a�the nuuucipalrh�ri�ithrn lb0 days nfler the alle�ed loss or rnjui��rs discoi�ered a r�olice sfatii�rg Ihe tinze,plrrce, nnd
circunistruaces U�e��eof, n�7d the anzou��t of conipensatron o�•ot6ier relief demnnded."
Please complete this form in its entirety by cle��-ly tyhing or printi�tb yoin�ans�ver to each question. Tf more sPace is
needed,attach additional sheets. Ple�se note th�t you �vill not be contacted by tefephone to clarify anslvers,so provide as
mucl� information as necess�ry to explain}rour claim, and the amo�int of compensation being requested. You ���ill receive�
written acla�o�vledgement once your form is received. The process can talce up to ten weel:s or longer depending on the
nattu•e of your claim. This form must be signed, ancl botl� pages completed. tf sometliing cloes not apply,w►•ite `N/A'.
5�1�� COMP�,�'I'�� �'�flTZM AN� OT�T�T� DO�UIV��NTS 'I'�: �I'i'� CL�RY�,
15 WES�' ����LO�� BLV�, 310 ��'�'Y I�AL1L, SAINT PAgT�,, 1V�N 55102
I=irst Name Nliddle Initial L Last Name���' 1 � �'� _
Company or Business Name n c� n �. RE�El�ED
Are 1'ou an fnsurance Company? Yes/No If Yes, Claim Number? N�V 1 3 2012
Street Address _ S � rn � L =�w I� U�' A '"
. �
�..[T'� +��,���C
City���� State rn/� Zip Code �/ Q
Day�time Phone (�_�Z1�^ C��ell Phone(�)��vening Telephone( -�--�_
Date of Accident/ Injury or Date Discovered ��� �-zC'�/� Timel :D � ��» p�»
�lease state, in detail, what occurred (happened), and why you are submitting a claim. Please indiclte why or how you
feel the City of Saint Paul or its empfoyees are involved and/or resl�onsible for your damages.
� U aff
'� � � ►
r - ��
Please check the bo�(es)that most closely represent the reason for compl�e�ting�tl �s form:
❑ My vellicle�-vas damaged in an accident .�ty vehicle was damabed diiring a tow
❑ My vehicfe was damaaecl by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ NIy vehicle tivas wrongfiilly towed and/or ticl:eted ❑ 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 You need to inclucle conies of all applic�l�le clocuments
Por the claims types listed below, please be sure to include the documents indicated or it will delay the handling of I
your claim. Documents WILL NOT be returned and become the property of the City. :'ou are encouraged to ]:eep 1
copy for yourself before submitting your claim form.
�Pi-operty damage claims to a vehicle: t��o estimates forthe repairs to yotu�vehicle ifthe damage e�ceeds
$500.00; or the actual bi(Is and/or receipts for the repairs
�BCTowing claims: (egible copies oPany ticl:et isstied aild a copy of the impound lot receipt
O Other property dama�e c(aims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for tlie repaii-s; det�ifed list of damaged items
O Injury claims: medical bilfs, i-eceipts
O Photobraphs are always �-velcome to document and support your claim but will not be returned.
Page 1 0#2—Please co3nplete a�id rP#��rn both pages of Claiin Foi•m
�'ailiii-e to compiete a3�d i-eturn l�otl� Pa�es�s`�il] resii3t i�i dela}� in #he 3ianclling of yo�7r c3aim.
All �l:�ims—>>lease com��iete tl�is section
� tiVere there witnesses to the incicient? Yes N Unla�owi7 (cii-cle)
Provide their names, addresses ancl telepllo� n�bei-s: �� �� �
P � .� ,v
Were the po(ice or law enForcement called? Yes No Unl:no�vn (circle)
If yes, what department or a�ency? Case # or report#
Where did tl�e accident or injury tal:e place? Provide street address, cross stceet, intersection, ame of parl:or facility,
closest landmarlc, etc. Please be as detailed as possible. If necessary, attach a diagram.�
Please indicate the amount yot� are seel<lI1fJT 111 C011lpellS1t1011 O]'\VI71t)i0l] WOLI�C� Ill:e the City to do to resoive this cfaim
to your satisfaction.
Vehicle Claims— lease com lete this section ❑ checl:box iFthis section does not a �lv
Your Vehicle: Year�G�_Mal:e Model /
License Plate Number o 3 State�_Coloi-�,��1/���
Registered Owner � f
Driver of Vehicle '
Area Damaged � � ` P '
�Cdi/
City Vehicle: Year Mal:e Model
U���,���� License Plate Number State Color
Drivei-of Vehicle (City Cmployee's Name)
�/Q 7`OCU/��Area D�maged
Ll'ur Claims— lelse com lete tliis section ❑ checl:bo1 if this section does not a>>1
IIow were you injured?
What part(s)ofyour body were injured?
Have you sought medical treatment? Yes No Plan�iing to Seel:Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss worl:as a result of your injury? Yes No
When did you miss worl:? (provide date(s)) I
Name of your Employet° !
Address Telephone �
Check here if you are attachinb more pages to this claim forni. Nnmber of additional pages '
By si;ni�zg this forn2,��orc are strrtin;th�rt rc11 infor�zation yor� Itm�e providerC is true aitrC correct to the best !
of yorrr Lnoivledbe. Unsigl�ed for��s ri�ill nnt be pf•ocesserl. '
S11IJY111tf1i2;a�C[�SL' C�lIli71 CCfIZ YeSIlI1 I/21JYOSC'CL/tl0/I. D�itC f�01'lll�V85 COIT1PI2tCCi �
Print the Name of the Person �vho Completed this Form:
Si;nature of Person Malcing the Claim:
Revised 1=ebruary 201 I
Saint Paul Police impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 79 FORD Licen�e#: RV21463 CN: 12237472 Invoice#: 140579
DatelTime Released: 10/07/2012 17:48 Tow Charge: $ 175.00
Released to: OWNER Storage Charge: $ 90.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: BECKY Tax: (7.63%) $ 19.45
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 364.45
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 364.45
on this form prior to leaving the impound lot.
�� j" - ` �� ,� � � :�� %
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Police Re ort made: Yes_No_IF Yes, CN , If NO, Why? '� �� � '�w�
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TO PRO(TE_ T YQl�f�l�IGW;fS EPORT ANY PROBLEMS/DAMAGE BEF RE LEAVING THE LOT
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State of Minnesota Ramsey District Court
CITY OF SAINT PAUL
PARKING CITATION
GI�Dtlon No113T412 0082goo�
Cl81Na��� �nent N�sA
�eD`P ��, "'
a 63 , ,
,� a .wN,��
�'
WINDY'S COLLISION CENTF, INC.
767 BUSH AVENUF •
ST. PAUL MN 55106
PHONE: (651)774-4426 FAX: (651)77'l_-0368
---— ---
**" PRELIMINARY ESTIMATE***
11/05/2012 09:30 AM
Owner
Owner. TEf�RY SCHNEIDE-fZ
Address: Work/Day: (651)776-0363
Inspection
Inspection Date: 11/0.5/20i"1 09:3'1 nM lnspection Type:
Appraiser Name: JON PHII..MALFF Appraiscr License# :
Address: 767 BUSH nVE Work/Day: (651)774-4426
Cell: (612)237-65'1..6
City State Zip: Saint Paul, MN 55106 FAX: (651)772-0368
Email: THFFUMS�c�MSN COM
Repairer
Repairer: WINDY'S COl LISION Cf-.N i ER Contact: JON f�HILMnL E E
Address: 767 E3USf i nVf. Work/Day: (651)774 44'16
Si f'/1Ul Home/Evening:
City State Zip: ST PnUI , MN 55106 FAX: !651)77'L U368
r:���a��: i i it_i uivi��ciiiviSN.C;UM
Vehicle
1979 Forq f_350 STI) 2 DR Convcrsion Van
Lic Expire: VIN: None
Veh Insp#: Mileage Type: nctual
Condition: Code: 7999Z3
Ext. Refinish: iwo Siage Int. Refinish: iwo Sta,ye
Options
Power Brakes
Damages
Line Op Guide MC Description MFt�.Part No. Price ADJ°/, S% Hours R
1 EC MOl OF2 f IOME_ SI[)ING 2& E30l1RD Replace E cor�omy �899 00� 30.0' SM`
2 EC 1RIM E30Tf-i SIDE S Replace Economy $"l9J u0` 120` SM`
3 FC fl11L PIPf Replace Fconomy $19`.i 0(i` SM`
3 Items
Estimate Total & Entries
Other Parts __ ___ $1.397.00
11/OS/90�2 09:33 AM I'age t of 2
WINDY'S COLLISION CEN I E. INC.
767 BUSH AVFNUE:
Sl. Pl1UL MN 55106
PHONE (651)774-44?_6 FAX: (651)772-0368
*'*PRELIMINARY ESTIMATE"*'
11/05/2012 09:30 AM
Owner
Owner: Tf RRY SCfiNt=lD� R
Address: Work/Day: (651)77F-0363
Inspection
Inspection Date: 11/05/2012 09:32 nM Inspection Type:
Appraiser Name: JON f'HILMAI_EE= Appraiser License#:
Address: 767 BUSI i f�VE Work/Day: (651)774-4426
Cell: (61'l_)237-6526
City State Zip: Saint Paul, MN 55106 FAX: (651)772-0368
Email: iHEFUMS�c�MSN.COM
Repairer
Repairer: WINDY'S COLLISION CENTER Contact: JON PHILMnLEE
Address: 767 BUSH/�VE Work/Day: (651)774-4426
ST PnUL Home/Evening:
City State Zip: S 1 PAUL_, MN 55106 FAX: (651)771-0368
Email: THEFUMS�c�MSN.COM
Vehicle
1979 Ford F-350 STD?_ DR Conversfon Van
Lic Expire: VIN: None
Veh Insp#: Mileage Type: /�ctual
Condition: Code: T999I3
Ext. Refinish: Two-Stage Int. Refinish: Two-Stage
Options
Power Brakes
Damages
Line Op Guide MC Description MFR.Part No. Price AD.1% B% Hours R
1 EC MOTOR HOME SIDING 28 t30/1RD Replace Economy $899.00` 30.0' SM' ,
2 EC TRIM BOTH SIDFS Replace Economy $?_99.00` 12.0' SM'
3 EC TAIL PIPF Replace Economy $199.00' SM' '
3 Items
Estimate Total &Entries
I
Other Parts $1,397.00
�1/OS/2012 09:33 AM Page 1 of 2 �
�
f
�
�
1979 Pord E-350 STD Z UR Convcrsion Van
Clairn tt: 11/OS/90�?0930 AM
Parts &Material Total $1,397 00
Tax On Parts Only �a� 7.6'L5`% $106.5?
Labor Rate Replace Repair Hrs Totai Hrs
Hrs
Sheet Metal (SM) $54.00 42.0 420 $2,268.00
Mech/Elec(ME) $85.00
Frame(FR) $75.00
Refinish (RF) $54.00
Paint Materials $34.00
Labor Total 420 I fours $"1_,268.00
Gross Total $3,771.52
Net Total $3,771.52
Altemate Parts C/00/00/00/00/UO CUM 00/00/00/00/00 Zip Code: 55106 Audatex Host
Audatex Estimating 6.0.843 ES 11/0512012 09:33 AM REL 6.0.843 DT 10/01I2012 DB 11101I2012
Copyright(C)2011 Audatex North America, inc.
Op Codes
" = User-Entered Value L - Replace OFM NG= Replace NAGS
EC= Replace Economy OE= Replace PXN OE Srpis UE-
19791�ord 1=350 SlD'1 UI2 Convcrsion Van
Claim#: 11/OSl7_012 09:30 AM
Parts &Materiai Total $1,397.00
Tax On Parts Only @ 7.625% $106.52
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal (SM) $85.00 42.0 4`I_.0 �3,570.00
Mech/Elec(ME) $85 00
Frame(FR) $75.00
Refinish(RF) $54.00
Paint Materials $34.00
Labor Total 42.0 Hours $3,570.00
Gross Total $5,073.52
Net Total $5,073.52
Alternate Parts C/00/00/00/00/00 CUM 00/00/OOI00/00 lip Code: 55106 nudatex Host
Audatex Estimating 6.0.843 ES 11105I2012 09:33 AM REL 6.0.843 DT 10101/2012 DB 11/01/2012
Copyright(C)2011 Audatex North America, Inc.
Op Codes __
` = User-Entered Value f_ - Replace O[M NG= Replace Nl1G5
EC= Replace Economy OF= Replace PXN OE Srpls UE = Replace OE Surplus
ET = f'artial Replace I_abor f_P Replace PXN FU -= Replace Recyded
TE = Partial Replace Price PM=- Replace PXN Reman/Reblt UM Replace Reman/Rebuilt
L = Refinish f'C I�eplace PXN Reconditioned UC fZeplace Reconditioned
TT - Two-Tone SE3 Sublet Repair N lldditional I abor
BR= f3lend Refinish I - Repair fI f'artial Repair
CG- Chipguard f�l fZ& I l�ssembly f' - Check
M- nppearance�Ilowance RP fZelated f'rior Oamage
This report contains proprieiary information of nudatex and may not be disclosed to any third party(other than
the insured, claimant and others on a need to know basis in order to effectuate the claims process)without
A���te� nudatex's prior written conseni.
- ' Copyright(C)2011 Audatex North America, Inc.
l�udatex Fstimating is a trademark of/�udatex North l�merica, Inc. _ ___
i>,{yo a���
11'OS;7017 nn�.:;;!A1��
�
State of Minneaota Ramsey District Court
CITY OF SAINT PAUL
PARKING CITATION
citation Na.: 620900826001
Cass No.:12237472
St.Paul Police Department
Vehfcle Licrnoe Number: RVZ'I4B$ State:MN USA
V�hicle VIN:
Make:FORO Modsl:NOT IN LIST Color:WHITE
Type:PASSVEH
Tab Month: Tab Ysar:
Date ot Of►enne 10I412012 Tims of otienae 22;13
StatutelOrd ORense
----------- __ ._____�_-----
157.03.a.20 Park vehicle at same Iocation more than 48 consecutive
hours• _.->^�""
ORenae Location: �
964 MCLEAN AV Intersactinp Stnet:
2nd Croas Strsst:
OR�n�s City:
St.Paul
Mstsr Number: Psrmit Zone: Sipns Vis�
Chalk In: Chalk Out: Parkad: (HH:MM) Tlme Zone:
Unit:960
omcer��pE0 D.Longbehn,Jr
Orticsr Numbsr: 408505
om�.�s: .
ORcer Number:
Report defective meters by noon the next business day
Call(851)288-9778
To pay your flne by credit card,wait 3 business days and then call
(851)288-9202
If cited for No Proof of Insuronce or No Drivera ticense in Possession,Proo/oI Insurance andlor
Grivers License should be shown in one of the Violations Bureau Locations listed below within
21 business days of the violation.
To payyour citation online' www2ndwebp�courts.state mn_us
For additional information or to psy your flns by telephona usinp a cradit cerd,
Call:-(661)Z66�202.
Plsass havs your citation numbsr and crsdit card availabls.
Mail paymenb to: Remssy Dlatrict CouR
TraRic Violationa 8ursau
16 Weat Kslloyp Boulsvard-Room 130
St.Peul,MN 66102•1613
Make checNs payeble to� Ramsey District Court
(A cherpe of up to 530.00 wlll bs asssased on all rsturnsd checks)
Vlolations Bureeu Locetions �
St.Paul Court Suburban Court Law Enlorcement Center
16 W.Kelbpg Blvd.RM 130 2060 WhiU Bqr Aw. 426 Grovs Stroet
St.Paul,MN 66102 Meplewood,MN 66109 St.Paul,MN 66101
OfFice Houra:8:00 A.M.-4:30 P.M. Mondsy-Friday(Excludinp Holideys)
Hearinp OReers:By appointmsnt only-call(661 y-2669202
Payment and Penaltles
Ityou wish to plead puilty for the oflenss(s)on ths rsverss side of the citation,you must do so
within 21 days from the date the citation la flled with the Court.It is your rsaponsibility to
prssent your payment n a timsly manner.Pleaas allow 6 businesc days tor procesalnp.A 56.00
late fse is added to all unpaid fine balances.ARsr 40 daya irom tho date the citation is filed with
the Court additional delinquent fsee may be sdded to all unpald flne amounta.
Additlonai penalties may include:1)referral to the Departmenl of Public Safety for tlriver's
licsnss auapension,2)arrest warrant issued,endlor 3)referral to a collections apency.
If ths oRense is a petty misdemeenor,failurs to appear will be considsred a plea of puilty and
weiver to ths ripht to trial unless the failurs to eppear ia dus to circumstancss beyond the
psraon's control(M.S.169.91).
Appeal
To plead not puilty,or to pleatl quilty antl oRer an explanation:
1)A�er 3 businsse daya,ce11 661-266 9202 to conflrm that the citation has been filed
with the couR.
2)If the citation has been filed,request a hearinfl oRicer appointment.
3)Whsn you arrive at the Violationa Bureau,tell the ceshier that you have a hearinp
oRic�r�ppolntm�nt.You must have a photolD wkh you. _�..r �'—
I understend that by PAYING THIS FINE I AM ENTERING A PLEA OF GUILlY to this oRense(s)
and voluntarily waive the followinq riyht to:
A.a trial to the court,if oRsnse is e p�tty misdemsanor,
B.a trial to the court or to ajury i/tha oRsnse is a miademsanor,
C.representation by counsel,
D.a presumption of innocence until provsn puilty beyond a rsasonable doubt,
E.conhont and cross-examine all witnssaes apainst ms,and
F.sithsr nmdn silant or to betiy In my own behalf.
1 also understand that if this oRsnse is a petty misdemsanor,the mazimum possible sentence is
5300.00;If thia oRenae Is a misdemeanor,the mazimum posaible aentencs is 51,000.00 fine
and/or 90 days Imprisonmsnt.
Citation No.: 620900826001
. � � -�w�� r �, � � °� _� t,��
y§
. ���.m � ��-�-" a����� _ - `
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��• �,
To d��P������t.��������
_ .: .,_.., ,�, . _:_,. ..
, ,i . <: ,
' �!':
Rafkl g V1�t8�1Qh$ ` .
i.imited Eine Sct� � Q�a�s
�ent � oE� �
- ,�=.�,:
su _e. _- _, .
�ee►�-�.�_w .�:;.. ,...:. ........ ....:... ......... E a�.00
Parked Yftheta Sigr�-Proh�lt r�, 33.00
LitniEed 1>atk EOne—SL Paul . ..... .� `38.OR':
.
No PaAdn9�—St Paui ......... ......... ........:. ........ . ... �.00
_� Parlced Over 48 Hours=St Paul.....:. ��
�; Parked Wifhin 20 feet of a Crosswaik. ......... $tF�l1;'
Expired Meter—University of Minn ............................:................. .........' 23.00
,. No PenrMt-University�.. -- _ .-,,.. ........................................ 28.00
� �m
- ..:.... .....�.. .....:�s-.�-,- .::...�..�-....,.,...
� � ,30 �_ , il "�.�«.»., � s<
�.:, CePko!�e�t Paikirlq VIoM�iori...... • ,� ,;
........ ..
Report defec�ve Capitol Comple Meters� 651 296-6741
" Handicepped T.one-Minr�eeWa 169.346.1 1. ..... ........ .......... 281.06
Expired Regi�ontE�T�s...... ........ ......... ......... .....:... 111.Qii
11i tl0
��?I@teMislln4 ��... eWr�is .+.. r�, :����� � .. .
�+ .. ....� 11 t.613:�...
� , ......... ........T:--=�`�-�`........ � �.�^.
_.�. `='' Lauderdale........... ...... 53.00
.....
Pa�on Hei�ts;.. .,...... ..... ........: ... 48.00
. ..
Ali other dfies,... . �....... ......... ..........� ....:. 38.00
' �� '0'��'����� ;
'S� C°{ Y..� �y�'"�_�, `� {'.'�'i"'�L v, _ � �`` ��,k �.Y��,'+��' ',
. ...{ '6�.��
�.v
8t Pa��utt
Room f��q��e., �
15 V11a� ��� ,
�Paul,MN 551�
� ��
; , re�mant Cer�sr (no �g offieer)
��5t�eef
��Ra�,fiAN 55101 � �
S ,_
3' i:" Y
��f�'&`.'� $:�/�WI`��:V �a�fffl�� � �
tis�:OPACers: Availabte by . f Only
P�caM 6 2H�6-9202 tasd�etJule en appofMment
' � �,. ���-'`
T- �tt�.:; .`r�s-p��+�e ` a�tm ap�ear�naw;.mucr►to
� �e�w� m hearing oiHc�r�o cort�� ,
��:. ���. �.:.. � �`{ :
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Eff�ive January 1,"�'��:`
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To fmd dt#lf yq�'S��peYa�e w1�iR a co�t:�r�g.haw much to
peY,late penai�s,or t�wc ttraee a�its�t ofAa�i"�c�test D�wr c�lOn�
piease wait 3 days and tl�sn ga ti�
or cail 651-266-9202 T
�' tf the fine Is not paid vr11Mh 21 days aitsrlh�'date the citaHoo is flled wid�
the cowt,a tS.6fl�IaEe featirlll be added. � � �
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To determine the flne amount for a citaUon rrith multiple af#enses„
�90 to: �.�f�� �
Li�ibd Fine Sohadule Por�itations Wittr One Offense .
•Paymeot of a Bne in any amount is a plea of gulity' '
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Amount indudes mandatory state and c�unly impo�surcha�ges of Z81.00
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�4-14A�lfs ....... ... 131.OQ
... ..
4b-191�aweY�' .: ` 141.p0
���6 fuNMas over k3►nit •• .............. 2�4.d0 ...,�
26—30 Nl�s over lxnit........................................................................ 281.00 ��'
31 ar mae.Mqea,arer Lirrpt(Court Required ff End�nge�g Box Ctiedted)........ 381.00
"Speedfng in a school zons or wa4c zor�e inc`eases tlie 8ne
Cia�U�ndN�p�jepf.4olKb.�i.i�n.us or ca�N 651-2H6-�202"
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I�atter�tive Driving(Failure to Use Due Care S 12t.d6"""�
Stop'Sign.Se��Glolatkm ` 131.00
Failure to Yreld of Way ......... ........: ......... ......... ......... 131.00
"FeG�tte to Yald to an Eenergenc�r Vehide In�the Firwa=
C��t�rabplq�.�1�u m'�85f 2�6�1U2 � ,
Etak�ed if�trlde�6Y! .....r.-... .. ..�., 121.tllt
1�9pe1 Wk�Ii�r TYtt . 13t.00[�
No 9e�be�:. ..�„,, 108.OQ
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� Paylnp eartdn i�tii�s mf��+ir rMvwkf�r�Mtn�A�• ��
N M doukt coMUlttM D�lnwyAi�Puh�'� ���1.
DrMng Hfter Suapeneion... ..... . ... . $281.
�D��<.. 28 ' `
Dri�kiBAtFgrCi�el�io�... � ' ;
No VaNd hriu�a thatl�e... . ........ . ....:... ......... ........: ......... 4 �� `;�
No Lic�r�ae in Pwsasaion................ .. .�101.00 or Displegm Violefiot�a \ r
...................
No Inauranoe or No Prooi o(Insurance".............................................. .........
"In lieu of payment,proof of insuranoe mey be displayed in person aC any
� cf our Yloledons Bureaus or subm�ted by mad to the Paul Court(see
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Ons Pfe�eR�Mieekg....... ......... ........, ......... ........_ ......... s 111.4�`,.
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' FM�s An�ubj�t To Chan�Y�Nof#cs ' r k
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