Misgina (2) NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
�L1i�mesntn Sta�e S1nliite 466.05 s•tates Iha! "...ei�e�y persar..,�rho clairns danmges fi•om nny nu�nicipalrty...sha/1 cnr�se to be presented to 1/ie
Kvvernin�ho�ly nf 1he mcmicipality r��ithirT/80 dnys nT er the alleged loss a•i�jtny is�liscovered a nalice s�nling llte�in�e,place,nnd
crrcumstcu�ces 1/�ereq/;nnd�Ae nrnount oJcompensn[ion or other i�efief demmrde�J."
Please complete tl�is form in its entirety by clearly typing or printing pour answer to each question. If more space is
needed,attach additionat sl�eets. Please i�ote that you may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to expiain 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 PAL'L, MN 55102
�
Fii•st Name ���%���C- Middle Initial Last Name �'���')� r2�'�
Company or Business Name, if applicable
Street Address �� ���� �G r�'E`� r����� %�'Y�e---
City ���v'::YGI�l�.t,� t C:,�-t�,���-- State j'V'�(�� `._7 � � �1'
Zip Code J �
Daytime Telephone (�t2 ) ����� � `� �� � Evenin Tele hone -c-��-2.
g P �� �=-
Date of Accident/ Injury or Date Discovered �2-� � U • �2-- Time ��� �I an�/pm (circle)
Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or how yau
feel the City of Saint Paul or its employees are involved andlor responsible.
� �..
t,�.�l� v� t�,� , -( x. C��,��.r�- L.,`Yt� k;�' � c .i t� u c�+,,
V"��c� r� rJ�L w�,��1c% ��� �a-- r�r -���.�' i�' �,� �- �y��Cc, ;.
Please check the box(es) that most closely represent the reason for completing this fonn:
❑ 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 dar�naged by a plow
❑ Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property
❑ Other type of property damage—�lease specify
❑ Other type of injury—please specify
❑ Othei- type not listed—please specify
In order to process your claim you need to include copies of all applicable documents. This is a general
guideline of what should be submitted with a claim form, but it is not all inclusive. You may be asked to
pi-ovide additional information depending on your claim.
O 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
� Photographs can be provided but will not be returned. � 71��°-�.-. LL`ti't-,�.- `�CL�G'c� ���j �``��(
G'`-� �Vlti )7�,�.c,vtl.:� �(�t -
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 thei•e witnesses to the incid�;nt`? Yes No Unknow (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?�� ��-� � i�u,�.s� Case#or report# i.(.t,�.�
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.
Please indicate the amount you are seeking in compensation from this claim or�'h� at you would like the City
to d� to resolve this clain to•your sa �sfaction. C!�vt,�C�-t'-� l�-�1-t.=z-���� '
� ��Lt,�U�;�.c� ' �,,.v�c� .v� � �� ����7 t�-�� ,
(.��cx�=yv� m u v� ��-�— - l�f 4�w�
Vehicle Claims -please complete this section ❑ check box if this section does not applv
Your Vehicle: Year 2f' �o Make it�c.,n tc�_Model C' :�. ti1 -�-
License Plate Number �`�l l �L State 1LL�J Color � �� !t� h - '�cn�--
Registered Owner -2� i �r�<,� v�r `�� 'T�r?W�+t� '�ab� � C�L�� �)
Driver of Vehicle v�.-c;�v�-- �
Area Damaged ►r���✓" �J���� ✓ `r- i�� �'Uc�Y C��Y
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Emplayee's Name)
Area Damaged
Injurv Ciaims - please complete this section C�check box if this section does not applv
How were you injured?
What pai�t(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 Medica] Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Natne of your Employer:
flddress Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
Bi�slgniag/ltfs jnrm,��ou u�•e s7ali�rg ll�al ull informutinn}�nu lrave provider/is frue u�rd correct!n!he best of}�our knnivledge. Unsigned
jor•ms will no►Ge processed. Strbntitling u fulse clain�cun result in proseculio�:. �/ ' `
Print the Name of the Person who Completed this Form: �� (-�'c-'-�t��'- �t�� G�u'l
Signature of Person Making the Claim: - ��f:-' �� - � ' �'✓''��� ~
Date form was completed �- � • � � Rcviscd April 2007
Saint Paul Police Impound Lot, 830 Barge Channel Road, vehicle Release Form �
Make: 10 TOYOTA License#: Q11 ELM CN: 12288997 Invoice#: 17630
Date/Time Reieased: 12/10/2012 10:31 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00 j
�
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: MELISSA Tax: (7.625%) $ 15.5b
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
i will check fhe vehicle for damage ar 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 1 will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made: Yes_No_IF Yes, CN , If NO,Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature Slz000
St. Paul Police Department for
Ramsey District Court
RECEIPT
Date/Time: 12/10/2012 10:31 Invoice #: 17630
Vehicle P{ate: 011 ELM/MN
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Arnount:
888751806 $ 53.00
Total Amount Paid: $ 53.00
Paid by: CREDIT CARD
KEEP THIS COPY F'OR YOUR RECORDS
FIXSEN AUTO BODY workfile TD: d65ae753
10957 93RD AVE N, FEDERAL ID # : 411481931,
MAPLE GROVE, MN 55369
Phone: (763) 424-5112
FAX: (763) 424-5531
Preliminary Estimate
Customer: TSEHAINESM YACOB,TEWELDE MTSGINA 3ob Number:
Written By:Jerry Fixsen
Insured: TSEHAINESM YACa6, Policy #: Claim #:
TEWELDE MISGINA
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impatt:
Owner: Inspettion Location: Insurance Company:
TSEHAINESM YACOB,7EWELDE MISGINA FIXSEN AUTO 60DY
(612)998-5778 Evening 10957 93Rd AVE N
(612)386-2688 Business FEDERAL ID # : 411481931
MAPLE GROVE, MN 55369
Repair Facility
{763)424-5112 Business
VEHICLE
Year: 2010 Body Sryle: 4D SED V1N: 4T4BF3EK1AR029442 Mileage In:
Make: TOYO Engine: �-2.SL-FI license: Mileage Out:
Model: CAMRY Production Date: State: Vehicle Out:
Color: Int: Condition: ]ob #:
TRANSMISSION Dual Mirrors Steering Wheel Controls Head/Curtain Air Bags
6 Speed Transmission Console/5torage RADIO Front Side Impact Air Bags
Overdrive Overhead Console AM Radio ' SEATS
POWER CONVENIENCE FM Radio Cloth Seats
Power Steering Air Conditioning Stereo Bucket Seats
Power Brakes Rear Defogger Search/Seek WHEELS
Power Windows Tiit Wheel CD Player Full Wheel Covers
Power Locks Cruise Control Auxiliary Audio Connection PAINT
Power Mirrors Telescopic Wheel SAFETY Clear Coat Paint
Power Trunk/Tailgate Intermittent Wipers Anti-Lock Brakes(4) OTHER
DECOR Keyles5 Entry Driver Air Bag Trdction Control
Tinted Glass Alarm Passenger Air Bag Stability Control
O1/08/2013 3:21:52 PM 058691 Page 1
Preliminary Estimate
Customer: TSEHAINESM YACOB, TEWELDE MISGINA 7ob Number:
Vehicle: 2010 TOYO CAMRY 4D SED 4-2.5L-FI
line Oper Description Part Number Qty Extended Lebo� Paint
Price$
1 REAR BUMPER
2 Refn Bumper cover lapan built 2.5 liter 3.0
3 Add for Clear Coat 1.2
SUBTOTALS 0.00 0.0 4.2
ESTIMATE TOTALS
Category Basis Rate Cost$
p�� 0.00
Paint Labor 4.2 hrs @ $52.00/hr Z18.40
Paint Supplies 4.2 hrs @ $32.00/hr 134.40
Subtotal 352.80
Grand Total 352.80
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 352.80
This is a visual estimate only, additional parts and labor maybe extra upon tear down. Parts prices subject to invoice.
MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
O1/08/2013 3:21:52 PM 058691 Page 2
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