Kelso NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
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Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipalify...shall cause to be presented to the
governing body ofthe mur�cipality within 180 days after the alleged loss or injury is discovered a nott�ating the�Y�i�`�ilace,and
� ` �circumstances thereof,and the amount of compensation or other relief deman ed."
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Please complete this form in its entirety by clearly ty�,ing or printing your ansv��er to eacti.q�a'estio�l:'-���more s�ace is
nQede�,attach additio�rEl sheets. Please note that yot� ��'i1l not be contacted by telephone ta clarif3�answers, so pro�ide 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 s:gned,and bo6:h pages completed. If someti�ing does not apply,write`h/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, II��S�,
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First Name ���YC� � _ _ �D�Iiddle Initial_,� Last Name���•�'•.� ��� 7 I ��
Company or'3usiness'�'�2,.e �►� �-��, �,
- — — — . �.,::�
Are You an lnsurance Company? Yes No lf Yes, Claim Number?
Street Address ��.� S� Y�SOYI J�"
��� ��- P ��:.�, �� p _��--
State Zi Code. � �
Daytime Phone(_) - Cell Phone(�I)� 26� Evening Telephone�) -
Date of Accident/Injury or Date Discovered I 0,a� � � 2-- Time am pm
� � �
Please state, in detail,what occurred(happened), and why you are submitting a claim. Please indicate why or l�ow you
feel the City of Saint Paul or its employees are involved and/or responsible far your damages. 1.J0�S �i1V� �
,� '� d� I _ -�ti _ �'4
t,.�:���-- � rl�rl-c� 0�„ c` ��� h�1��1�, �In�=�i'
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,,,,� ��r � v k-.� J I I h ' 1 Va u'
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Please 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
n My v?hic?e was wrongfull3�tewed�n�/or ti�keted ❑ I was injured �n City propert;
❑ Other type of property damage—please specify
- ❑ Other type of injury—please specify
In order to process your claim y�::^Ppd to include eopies 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 fonn.
� O Properly 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-qlease complete this section
Were there witnesses to the incident? Yes No Unknown (circle) . , _
Provide their names,addresses and telephone numbers: �
��'ere the police or law enfoi�cement 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 diaga�n. �- c,
`1�, h���i ;,.:�c �l �
lY��(,vs '" .p,�l C�f� ��..� �(i c'1'1-�-HGt,+-�,�..--� 5���e..,
Please mdicate the a unt you are seeking�n compensation or what you would like the City to do to resolve this claim
to your satisfaction. - ���, � �
�
Vehicle Claims-nIease complete this section ❑ check box if this section does not applv
Your Vehicle: Year�Q�Make c�,,�, � a(„� Model �/� {�,�
License Plate Number�o�„)il y� State�Color �. ��� t ,y�
Registered Owner - --�-
Driver of Vehicle ,r�� �. � ���
Area Damaged�,����- ����-�-n�
City Vehicle: Year Make Model
License Plate Nuinber State Color
Driver of Vehicle(City Employee's Name)
' ' Area Damaged - ' ,
Iu'u► -Claims- Iease com lete this section heck box if this section does not a 1
Ho«�were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Plamling to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
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
�heck here if you are attaching more pages to this claim form. Number 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_��=�-\Z.
Print the Name of the Person who Completed this Form:_��1� ���
Signature of Person Making the Claim: , ��(� ,�n��?� ��
Revised February 20ll
7.��:� ,�luL�� ��, �f� � � �� �� Ee 006319 .��
Bolts Roac�side Service r,��, __ �
,
651-698-3659 • www.boltsroadsideservice.car�
Dlsc�almer:Botts Roadside Senrice�ri{I not be respansibie for los_ TOWING
�f113�E iu�;��h!!;�P WhI�E?�1P,1!in t^�yo+�.',�'i(1ChEd,S2I�/!C�pi StC1`•`
A����e ti�p . _ REPORT
� NnM���l l:� kt' ��-;% RA�-M�ETHOD
ADDR�SS � �'CASH
C� � ��1' _�- C7�Cf#E-f;ff".� ..`
CITY � STATE Z�P ❑CREDIT CARD
G %. �-'l i ?`, r, -j� ;
� PHONE ❑ON ACCOUNT
DATc TIME 'J AM REC]UESTED BY MILEAGE �.
��/ ` a:r�r �,p pM j �!�� BEFORE TOW
YEAR Ml�CE/MODEUCOLOR � �Q 2 3 s s � a e io u +a ia ,s is
�f t N�} 1 ,r�.
DR�VER REGISTRATION NO. LICENSE NO.
t : (. { , ' r, """ ,� ,`i
LOCATION F VEHICLE TOWED TO
�-r A i ' ;c`, ,� ---•'^'
MILEAG� SERVICE TIME EXTRA TIME
FINISH FINISH FINISH
START START START
TOTAL TOTAL TOTAL
SPECIAL EQUIPMENT
❑SLING/HOIST TOW L�FLAT TIRE O SINGLE LINE WINCHING
❑WHEEL UFT ❑OUT OF GAS ❑DUAL LINE WINCHING
❑FLAT BED/RAMP ❑WRECK ❑SNATCH BLOCKS
❑START ❑RECOVERY ❑SCOTCH BLOCKS
❑LOCK OUT ❑ �
I HAVE BEEN ADVISED THAT MY VEHICLE MAY BE DAMAGED IF WINCHED,TOWED,UNLOCKED OR
LEFT ON UNATTENDED PREMISES.I RECOGNIZE THE DIFFICULTY INVOLVED AND I AGREE NOT TO
HOLq THE TOWING SERVICE RE�PONSBLE FOR SUCH DAMAGE SHOULD IT RESULT.
SIGNATURE OF CAR UWNER OA AGENT � DATE
• � � �
FEMARKS MILEAGECHG.
� �`"� TOWING CHG.
�n
LABOF CHG. -
STORAGECHG.
, `` SUBTOTAL '
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SIGNAT R OF TOW OPERATOR � � DATE
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AUTHORIZED SIGNATURE DATE
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Rodriguez Auto Service
411 Wabasha St. S INVOICE
St. Paul, Minnesota. 55107
Phone-651-227-6298 Fax-651-224-2970 Org. Est.#031056
REMEMBER TO TELL YOUR FRIENDS AND FAMILY
INVOICE Print Date : 11/02/2012
KELSO,MANDY 2002 Saturn- SL- 1.9L, In-Line4 (116CI)
363 STINSON ST Lic# : KLV284- MN Odometer In : 0
Saint Paul, MN 55117 Unit# :
Home 651-470-2634 Vin# : 1G82H528027265512
Cust ID : 301 Hat# : Ref# :
Part Description /Number Qty Sale Extended Labor Description Extended
NEW TIRE-215/45/ZR17 DISMOUNT, MOUNT AND BALANCED 1 20.00
125350 1.00 97.00 97.00 TIRE.
Shop Supplies 2.91 2.g� Hazardous Materials 2.00
Org.Estimate S 129.53 Revisions S 0.00 Current Estimate s 129.53 Labor: 22.00
Parts: 99.91
Sublet: $0.00
Sub: 121.91
Tax: 7.62
Total: 129.53
Bal Due:
[Payments-Cash-$129.53]
web site(www.rodriguezautomn.com)
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees permissi
to operate the car or truck herein described on street, highways or elsewhere for the purpose to testing and�or inspection. An express
mechanic's lien is hereby acknowledged on above car or truck to secure the amount of repairs thereto. Warranty on labor is 30 days, and
varies on parts. Warranty work has to be performed in our shop&cannot exceed the original cost of repair.
Signature Date Time
Page 1 of 1 Copyright(c)2012 Mitchell Repair Information Company,LLC
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