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Ward NOTICE OF CLAIM FORM 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 may or may not be contacted by telephone to discuss your claim circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. 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 `.��t1��r Middle Initial ��l Last Name�,,�V�`\X!ti- }��4'�� Nf�. r ^ 2013 Company or Business Name, if applicable r�� Street Address._ �`'�_.`�I �=r� ; �_�I �c _ __.— ^- ., . r��.,..��C City �r.�r`l�ti 1 State 1�/1�l Zip Code �j I 1 Ly Daytime Telephone (t�i i ) �2�- �SS� Evening Telephone ( (.v}2 ) ��?�'�- ��;r-� Date of Accident/Injury or Date Discovered I�I2�!'� Time am/�m)(circle) C Please state, in detail, what occurred, 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. � j� ,F �. � ' �' m� � �s'�G 'v��,+�� i rS�=fy. z�� ,� �- �;�� - ia��'�►M ��-� � �t c�� la � ni rz Ylc}f- �Y, � `� t . ( Y1!'�i l.i'Nl�� c" � l�' � � � 6 " � Str(��ic'v1 �'f rr�� u�-�r�'r s�� . �n �,� �4-��,�� Ihu�l P�t��,��,��( a,n� �o�t�.r'�P r�c `t -F�}�C l � 1 � I w �f�1" � A �-�, V DLI S�'rN W�(s el.�S� �`�Zt CKr ' �_,��?_ �i'� � - � � � �i: � �� " 1� ti' ' s:x.;,�� '�anc ct'1' }�� we�e nr.�- nr�d as pruf� �� fief�-e.—��.f"�t� ►;��-�ct.e:t . Please c�eck the box(es) that most closely repfesent the reason for completing this form: ❑ Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow �Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow ❑ Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property �E��VED ❑ Other type of property damage-please specify ❑ Other type of injury-please specify_ F�a--� 20�3 ❑ Other type nat�ist��=��ease specify In order to process your claim you need to include copies of all apnlicable documents. This is a��r�alC'�� guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to provide additional information depending on your claim. '�Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts O Other property damage: repair estimates, detailed list of damaged items O Injury claims: medical bills, receipts O Photographs can be provided but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form Failure to provide a completed claim form will result in delays in processing. Notice of Claim Form, City of Saint Paul,page two All Claims—please complete this section , Were there witnesses to the incident? Yes No Unknown (circle) If yes, please provide their names, addresses and telephone numbers: 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 helpful, attach a diagram. {-�t�,�, c�+ 1 Gr"i�tLriLt,( I �• ; f'1l Gi�1^ tt.- `d (,i.i'i ZrS� i�c�. `f"F2� � ��r�s�� t°� v�i � �4 — i-tr�� s�dt �f S-ty��f • Please indicate the amount you are seeking in compensation from this claim or w at you would like the City n� n��_ c, r1 (1 .,� � to do to resolve this claim to your satisfaction. �� f �i�.�N W _[,l � viLi�( .S}��1 ./�A,i�l'G�!�(`�i,1�xr r a. � �L'�'*z",7� -� �3 3.�� -� t�x Vehicle Claims—please complete this section ❑ check box if this section does not applv Your Vehicle: Year 2�'��% Make '(�I�'1Q�Vv I�t� Model M L.l_l i}�tA License Plate Number SD� �O dU �State Ni I�( Color ��Y�t v Registered Owner �! � ' !�/l . 1i Gl Driver of Vehicle G'U 1 i�(�. (�l! , �ti',;�G� Area Damaged �"�U�+��I�GiVI� W Cp� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniurv Claims—qlease complete this section �check box if this section does not applv 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 Did you miss work as a resuIt of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone '�`I Check here if you are attaching more pages to this claim form. Number of additional pages 3 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. Print the Name of the Person who Completed this Form: .�,1n 1 i'l�c ��.�,�1 r�� Signature of Person Making the Claim: �V��'�� I y�l`1�� — Date form was completed I��i(,�( �'� Revised Apri12007 : 206362 362964 ROSE�A�E CUSTOMER # , CI�IEVROIEt *INVOICE* 35W & COUTY ROAD C JANIELLE WARD ROSEVILLE, MN 55113 9 5 6 SAINT PAUL AVE 651-636-0340 SAINT PAUL, MN 55116 PAGE 1 www.rosedalechev.com HOME: 612-327-8557 CONT: 612-327-8557 BUS : CELL: 612-327-8557 SERVICE ADVISOR: 8004 AMANDA MORUD COLO'R 'YEAR ' iVIAKE/IVIODEL VIN' LICENSE ' MILEAGE IN /OUT< TAG GRAY 08 CHEVROLET MALIBU 1G1ZH57B38F164090 SDH306 36903 36903 T1339 D�L. bATE PROb. DAT� WARR. �?CP. Pf?03VlISED PO f�0. RATE I?AYMENT INV. DATE OlJAN10 D WAIT 30JAN13 30JAN13 a.o, OPENEb REnaY oPTioNS: ENG: 2 . 4_Liter_MFI_DOHC_HO_ECOTEC 07 : 17 30JAN13 08 :42 30JAN13 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL A'' CUSTOMER STATES :Right ''Fronit fpassenger) Tire sti'11 not holdinq �ressure - this has been an on-going issue since September and l <lh.ave requested it get :looked at s�Veral :times . I am putting air in approx every 2 weeks . Tire was resealed in November but the issue r�main�. In late Septe�ber, I ne'eded to purcha�e 2<; tires as there was a nail found in one of the back tires . . . this d�d not allow m� to take advantage af ,'the ,buy 3' tires, get one free offer that was being promoted because I was t ld the front ' tire wa� fine. i ' �� : 18CVZ3 CUSTOMER STATES :Right Front (passenger} �,, f/J' '��. Tire still not hc�.l;d��.�-.p-res�ur:e; thi.s..Y�as �r � been an on-going issue since Sep�eml?er and ': ',; � ��'"��.. ;have , request�r3 i�:.�e�;::1.c�o.l�ed.::a� aev��'a1. " c��: , t�� i ,�, times. I am put�3ng air in ap�rox- every 2 �� Tw�F 'weeks . Tire was resea�.ed in, �c��x 1��. t��.: ,`''�� 'h -, t ` ; issue remains. �,n .late.YTSeptember, � `needeci ��t tto purchase z: ��- �.�=`��r� �-�- �. ��,�.1. : �_= e �` found in one �f the back tires ' �-his c�id ; � � 'nn� al�ow me �� 1�� . �� b�y �, ,_. . � �, �° tires, get one �ree offer that was be�.ng' - = ` � promoted 'becau�e ::T, was=.�e�.�:e�. ��'i� frc��t ti:'�e was fine. 78:64 CLD 25 . 00 25.14.0 1 9597624 WHEEL 225 . 00 225 . 00 � 225 . 00� �.,_----Y � TTRE I�CHTN� 1 15263240 VALVE KIT 8 . 96 8 . 96 �� : TTRE MA�HINE ' ', ' PARTS: 233 . 96 LABOR: 25 . 00 OTHER: 0 . 00 TOTAL LINE A: 258 . 96 36903 INSPECTION FOUND NAIL IN TIRE AND RIM TO BE BENT. RECOMMENDED "REPLACEMENT QF RIM AND REPAIR TIRE_ TIRE WAS, REPAIRED' AND IMOUNiI'ED AND BALANCED ON NEW RIM. TIRE WAS THAN RECHECKED FOR LEAKS NO LEAKS WERE FOUND ' ' , ' **************************************************** STATEMENT OF DISCLAIMER E3ESC�IP7RON T07ALS The factory warrenty constitutes all of the warranties with respect to the sale of this �//�,vNfTV LABOR AMOUNT item/items. The Seller hereby express�y disclaims all warranties erther express or implied, �, �Q� pARTS AMOUNT including any implied warrenty of inerchantability or fitness for a particular purpose. Seller neither assumes nor authorizes any other person to assume for it any liability in connection � GAS,OIL, LUBE with the sate of this item/items. � SUBLET AMOUNT "Remanufactured parts meet GM approved service part requirements and are made from prev� use components in a process that involves disassembiy, inspection, cleaning MISC.CHARGES update of software and replacement of parts as appropriate,testing,and reassembly. � TOTAL CHARGES Refurbished parts meet GM approved service part requirements and are previously used O�� LESS INSURANCE pa s a are inspected,cleaned, tested,and repackaged.By leaving your car for servicing, you are expressly consenting to the installation of either new, remanufactured, or ��A��-� SALES TAX refurbished parts at the discretion of the servicer." vpY�a.� • PLEASEPAY X THIS AMOUNT CUSTOMER SIGNATURE �oo.,;,�,��A�P �� SEA�.�E��E roE z s�z� CUSTOMER COPY CUSTOMER #: 206362 362964 �O��A�E - � cHEVRO�Et *INVOICE* 35W & COUTY ROAD C JANIELLE WARD ROSEVILLE, MN 55113 9 5 6 SAINT PAUL AVE 651-636-0340 SAINT PAUL, MN 55116 PAGE 2 www.rosedalechev.com HOME: 612-327-8557 CONT: 612-327-&557 BUS CELL:612-327-8557 SERVICE ADVISOR: 8004 AMANDA MORUD COLQ:Fi Y�AR t1�iAK�/MOf��I. 1fIN Ll�,'�N$E. >: MI1.�,4fsEltJI;0i1T TACy: GRAY 08 CHEVROLET MALIBU 1G1ZH57B38F164090 SDH306 36903 36903 1339 €1E�.C?A7'� RFtUC?. b1�7� ilV1�4RR,��, f�Fi(JN4lSED s; PO E�10. I�AI'E Pi0.YMEN? IIVV. DATE O1JAN10 D WAIT 30JAN13 30JAN13 �,p:�p��p >R�at��: `` oPTiorvs: ENG: 2 .4_Liter_MFI_DOHC_HO_ECOTEC 07 : 17 30JAN13 08 :42 30JAN13 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL B RECAI.,L 1210� - SHIFT L;EVER`` II�I7ICATOR. MAY NO`T` DISPLAY �ORR.ECT CEAR. : CAUSE: E _ 3 7 C'"JZ 'C�.iSTOMER>STAT:ES:Transmi 5 s i on Shaf t Cabl e Recall Notice ' 786':4 'W tN/C) < 1 19210732 CABLE KIT (N/C) STi�LL, 3', ' '' ` PARTS : 0 . 00 LABOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE B: 0 . 00 36903 CABLE CLAMP INSTALL UNDER RECALL 12106 > ***+�*;�***�:�**�;►�*��_*:,�*,�.*�**,****�_�*******�***�.*.�*��*:� C MPVI-MULTI POINT VEHICLE INSPECTION , WCI MPVI-�'lULTZ�� P��`NT UE�I�C2°;E. .ZNS�P��'�'��ON:" �� (N'�C) < 7864 ISP ' ' �� ' _.,, .. _�� .- , _. ... PARTS :''. >' 0 . 00 LABOl�":' ' D .0 0 OT�-i�R:: � : .fl. Q�. fi0��- LINE C: >� 0>>,. 0(7 3 6 9 0 3 INS.PECTION COMPLETE = ° =` - ` ;; -:_� . ! _ **************************��##****��*�*��*�*�*.**** ' 2'!.2 5 '' CUSTOMER PAY SHOP SIJPPI�T��I��l�i��'.� g�� _��-�� i� WAIT Web Appt created ' ' - ', . .... �' �: . =. ° ;:? •:. � �" '' > 2d1��-0�-�'�28 1� :22 ;32pt�t-:'��k ;�r�.. _=�� - �"% � ;.;, by Janielle Ward _ _ __ _ ____ _ _ __ __. _ _____ __ _ __ __ ___ ___ ___ __ __ p�SCRI�!TtON TtJTALS STATEMENT OF DISCLAIMER 2 5 . 0 0 The factory warranty constitutes all of the warrenties with respect to the sale of this �// , : LABOR AMOUNT item/items. The Seller hereby expressly disctaims all warranties either express or implied, �� Q,(,� PARTS AMOUNT 2 3 3 . 9 6 including any implied warranty of inerchantability or fitness for a particular purpose. Seller O . O O neither assumes nor authorizes any other person to assume for it any liability in connection � GAS,OIL, LUBE with the sale of this item/items. �, SUBLET AMOUNT � . �� "Remanufactured �arts meet GM approved service part requirements and are made from 2 2 5 previou y u e �m�bnents in a process that involves disassembly, inspection, cleaning MISC.CHARGES update of software and replacement of parts as appropriate,testing,and reassembly. �� TOTAL CHARGES 2 61 . 21 Refurbished parts meet GM approved service part requirements and are previously used � . �� pa—fr s f a are inspected,cleaned,tested,and repackaged.By leaving your car for servicing, LESS INSURANCE you are expressly consenting to the installation of either new, remanufactured, or �u�'QA A� $AIES TAX 16 . 6 7 refurbished parts at the discret�on of the servicer." K�b� X PLEASEPAY CUSTOMER SIGNATURE �THIS AMOUNT ��.7 . S g �: �oo�„a�,2�AoP.��.SEq��E��a��E rPE 2.5�2� CUSTOMER COPY � �O�EC)NLE�HEVkOLtI 2845 HWY 35W R05EVILLE, MN 55113 08:41�45 01�3i��2013 p00000001755530 Merchant ID: p'L6317�.6 7erminal ID: 846210725889 CREDn CAR� VISA SALE )(XX?G�J(XX?C�C�(X3464 CARD� 362954 INVOTCE OOG751 Batch #: 043756 ' ppproval�ode: Swiped �, Entry Method: Online ' Mode: ��7Z,$� � SA��AMOUNI� C.USTOMER C0�'Y �