Pinkett _ _ _ RECEl�Ft�
NOV 2 � 2012
NOTICE OF C�j�I���RM to the City of Saint Paul, Minnesota
Minnesota State Statute 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 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 egplain 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 O'�HER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 �ITY HALL, SAINT PAUL, MN 55102
First Name r��� t.� Middle Initial � Last Name �- � �'Z� �
Company or Business Name �
Are You an Insurance Company? Yes No Yes,Claim Number?
Street Address ��0� `--v`����! � � � �'�� �
City � � ����" State �� Zip Code 5� ��
Z 7�C��
Daytime Phone��� ���1 Phone(�j)� `� ''Evening Telephone(� -
Date of Accidentl Injury or Date Discovered �� �-� �� �Z Time 7�3 b am m �
Please state,in detail,what occurred(happened),and why you axe submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involve and/or responsible for your damages.
� ��!� �Q,�" C7'V�� �T 1� /�'✓�L '
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Please c�th`e bo(es)that most closely represent�he rea�n for co`inpleting t�his of rm!
❑ My vehicle was da�naged in an accident ❑ My vehicle was damaged during a tow
�GIy 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 tic�Ceted , ❑ I was injured on City property
❑ Other type of property damage–please specify � t�� ' S—'�"
—�
❑ Other type of injury–please specify
In order to process your claim you need to include copies of all applicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. 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 andlor 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 o�damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
____..w,._._., _ _ �.. _�,
�Page 1 of 2–�se co lete and return both pages of Clai�n Form
. �
S� �� � � � __ ---. ���
,`,___._ _._
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims- lease com lete this section
Were there witnesses to the incident? Yes No Unlrno �(Ic�ircle
Provide their names, ad resses d telephone numbers: � �. � J��`` 5��
,�JQ�' �7" �1�-� �- 31.a a, • C.o S l ?3 - t
Were the police or law enforcement called? Yes - No Unknown (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. � �.�'VLGLI.C�
,�'k/
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
---- ' r,.,-:�_ - -, _---- -----
_ �_� .._4.,. -- ___ _ ---- ---
Vehicle C'.la' - lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year�C7o� Make -�t7?/�. Gl. Model /-�-e_C-�'✓�- _
License Plate Number � Sta.te M. Color I/n �C.-C�IG �
Registered Owner A'�� c--��� —�t D..� �'�'C
Driver of Vehicle K A'�� L��� ti�«�
Area Damaged "�a-�J �� �� �--�� t �
City Vehicle: Year Make Model
License Plate Number Sta.te Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniury Claims-please complete this section �check box if this section does not apply
How were you injured?
What part(s)of your body were injured?
Have�you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
- --- - ---c- - - _ ____ _�_ ____
� --- - Yes � _ No— — -- - --
Did you miss work as a result of your injury.
When did you miss work? (provide da.te(s)) _
Emplayer: -- --_ - - -- -
Address Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages�.
By sig�ing 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 �� l � l�Z
Print the Name of the Person who Completed this Form: 1°l f�� ���� Q t � �����
Signature of Person Making the Claim:
Revised February 201 I
Customer Invoice TIRES PLUS Service Advisor:
097081 M!IDWAY 07 MATT.
10/25/2012 300 SNELLING AVE N 651.644.1975 �
' SAINT PAUL, MN. 55104-5330 = (�Y'�'1 �(!�.�1�'`(d�r2.
BARKER, DARWIN — M�� �2.�/�d 2005 HONDA ACCORD EX�.- ��y�.�,�/ �
18776 FARMSTEAD CIR ��� Lic#: 090JKU MN Vin#: {�(��, C�,
EDEN PRAIRIE, MN 55347-35 2 �(y.J�- In: 10/25/12 9:11AM Mileage: 88,943
952.270.3852 �/ 1� Out: 10/25/12 5:45PM
Store#244226 RETAIL SALE
Rev Hist Unit Extended Job
Description _ IArticle# ID Qty Price Price Total
-- — - __ __- - — - - - — — _
OTHER PASSENGER TIRES 1 01 110.39
7099716 YOKOHAMA AVID ENVIGOR 205/60/16 7099716 55TN 1 110.39 110.39
DOT# CC2082D0312
BASIC INSTALL PACKAGE 1 01 18.97
WHEEL BALANCE PARTS 7005989 55TN 1 3.99 3.99
RUBBER VALVE STEM 7015040 55TN 1 2.99 2.99
SCRAP TIRE RECYCLING CHARGE (1) 7075078 55TN 1 2.99 2.99
WHEEL BALANCE LABOR 7006010 55NN 1 9.00 9.00 �
TIRE INSTALLATION 7015016 55NN 1 N/C N/C
Technician(s): - ..
55 NATE CHANDLER
Payment History: � Summ'�ry:
Visa 4473 138.54 008756 Parts 117.37 �
Total Tendered 138.54 Labor 11.99
Shop Supplies 0.00
Sub-Total 129.36 'I
Tax(7.625°/� 9.18 !
��----� ,
Total \ $138.54 i �
I have received the above goods and/or services. If this is a credit
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card purchase, I agree to pay and comply with my cardholder ',
agreement with the issuer. I
Rev I
Revision History: Amt Init
Customer Signature 1) 10/25/2012 10:42AM 106.11 BARKER, DARWIN IN PERSON
Initial here to indicate you have received
the Tire Limited Warranty Book.
All parts are new un/ess otherwise specified.
I acknowledge notice and oral approval of
an increase in the original estimated price.
Signature or Initials
TELL US ABOUT YOUR EXPERIENCE AND RECEIVE$5 OFF YOUR NEXT PURCHASE OF$25 OR MORE!
To complete a short survey Call 1-800-754-9817 or go to www.TiresPlus.com/survey; Enter code 244226-097081
Write redemption code: . Only ONE(1)redemption allowed per invoice. Offer expires 6 months from date of invoice.
Good at participating locations. Must have valid redemption code. May not be used to reduce existing debt. No copies accepted
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