Boa Amponsem fi�s����c�e�r�s ���� �E(��c���lat�ce a� C[a�E-�� -�a ���y of �air�f Pa�� � .:
' ll4innesot3 State Statute 466.05 NOTICE OF CLAIM...(Elvery pe�son...who claims damages fiom any
municipality...shall cause to be presented to the goveining body of the municipality �vithin 180 days after the
alleged loss or in�ury is discovered a notice stating the time, place, and circumstances thereof, and the amount of
compensation or other relief demanded. �
Please complete tl�is forr�� in its entirety by typing or printing your answer t� �,��tion in
tl�e space provided. If additional space is needed, please attach addition�ee�-'s�.
MAR 1 2 Z�'�3 -
PLEASE RETURN THIS Office of City Clerk�i r �� ���,�b i��
COMPLETED FORM T0: 170 City Hafl
15 W )Cellogg Bfvd
St Paul MN 55102
Your Name: I� � (ll �� �"'� ��C'�� ��r���V✓` ,
_ . -Street Address:- �`J-�� I_ --�;�tC. - - l - -�-
�.�_� _ �� �_ _ _ �_ - � �._. ---- .._____ - -- -- - -_._�----:._ _._ _ .--
City: �C'--�-1(,�-11 State: � � Zip Code: SS -� �--j
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Daytime Telephone: I�S�) ���' � � � � , Evening Telephone: ( �
Date of Accident or lncident: � �7 3 �Day of Weelc; S�-�Jr��� Time: am or pm (circle one) ,
� '
Please state, in detail, wi�at occurred and ti�e circumstances surrounding the event. Indicate how the
City of Saint Paui is involved, and why you feel the City is responsible. _
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Please indicate your reason for completing this form: '�'� �„�- �,.�ti/ �11�d ,,� �� �
� mc���l.� a a t}�tn.P�S 1� C r�.t1 P�-� b�.t ��u[cl�� r��� ;,
C:1 Veliicle accident f7 Oth�r p�'o�2rty damage (please provide specifics below) �i�;��j;
� Vehicle was towed �':ii��
Vehicle damaged O Other in'ur to �����I�
) y person (please provide specifics below)
�����.
O Slipped and fell on City property ���
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Please pr-ovide the names and telephone numbers of any City empioyees involved in this �i �
incident/accident and t�ow tl�ey were involved:
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If your vehicle v��as involved, please complete the follp�Ning; cm G]
License Plate Number: J � `
Year; mal.e, and model: �(��1 ����un lm�'�-�I (l� .1 _ � , '� L�•
Extani and area damaged: �"�+" �`� �
Was a City vehicle involved in tliis accident/incident? Yes No (circle one)
If yes, please complete the following: Type of vehicle .
Year, mai<e, and model
• Color of vehicle License Plate Number: -
Description of vehicle
Location of accident/incident (please provide specifics sucl� as street address, intersection, cross streets,
park name, facility name; etc.):
,
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---_P_�ea.s.e_dra.w. or_attach. a_ci_i_agram_.!f..a.PPlica�le_----- ----- --_ _._..----...--•—------ .-- �-
----- __ __ ----------..._..--
� [ �C��- �'�� C�.� �r�-p � �� (,i c�.l��- .
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Please specify the nature and extent of tl�e compensation or other relief you are requesting. Please
attach copies of any bills, receipts, tici<ets, or other documents to support your claim. If you are
claiming damage to a vehicle, please submit two estimates. .
Were there witnesses to this accident/incident? Ye No (circle one)
If yes, please give the names, addresses and telephone numbers of the witnesses:
(�n U-�t`�sc..K� Q�,c� �S 1 �'��$ ��`f
Were the police called?_ Yes No (circle one) If yes, what department or agency? •
Police report number:
Please print the name of the /� r �
� c � c' (��p�.'v�
erson com leting this form: (' '`�`��}� ; ��{� `�`� 1'"
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Please sign your name: ����' �
Date form signed: ���— � 3
. ! ,
Risl< Mgmt Division - Revised 1-30-01 ;'��?��'�
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QUOTE TIRES PLUS SERVICE ADVISOR:
2530783 3595 KRESTWOOD LN 44 PATRICK
03/11/2013 EAGAN, MN. 55123-1018 651.452.4091
BOA, MILLICENT 2001 NISSAN MAXIMA GLE
3301 COACHMAN RD V6-2988 3.OL DOHC
APT 221 LIC# SMY497 MN VIN#
SAINT PAUL, MN 55121-2802 IN 01/01/70 12:OOAM EST. MILEAGE 0
Store# 244209 QUOTE .
Article Extended Job
Description Number T# Qty Part Labor Price Total
NON-SYSTEM SERVICES 44 229'�8
SPLASH SHIELD AND FASTENERS 7003189 1 197.28 �97•2$
INSTALL SPLASH SHIELD 7003348 1 31.80 31.80 .�;
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Prices valid for 30 days. Summanr
Parts 197.28
Labor 31.80
Shop Supplies 1.91
Sub 230.99
Tax 14.05
� Total 245.04 �
4�
THIS IS NOT AN INVOICE- DO NOT PAY
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. ".� . . . ... .. _ .:. . � {�`..,-, ,....,.-.�� .-, n�rl� +.�r 1R/nrrn�r.tv ir.+nrrn�hinr� �. � � �'Y.�
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicie Release Form
Make: 01 NISSAN License#: SMY497 CN: 13036203 Invoice#: 19943
Date/Time Released: 02/23/2G13 08:02 Tow Charge: $ 123 95
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: MAI DER Tax: (7.625%) $ 15.55 � �
. ;^r
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50 �
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: $ 219.50
on this form prior to leaving the impound lot.
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9 p �,,�v;�,;,,,,� �'�� 6e C _��. �' ;�7���J�� � � ,����%'�"��,�t'U�L�3
Dama e and/or other roblem: �� � �
_ - . _ ;' J ` , :,%
� ! / �. .;� �.���.. jIGY!'�_i1 �� ���ri�yl %��v� `t Y;o'� .
�'Z''Y�'jr1'YlY y�-- -E �✓'f (,rt �/���. � 1,.1.� Yt���a{: LI �' ��`i=W'v� �'�"�Va c . .�v _ � r .
/ ` v f r �...y
Police Report made: Yes_ No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS, REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
,
, � ,f`y'�_� 5i2000
Signature_ -
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