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Raymond ►�ct,ttV�D MAR 2 6 2013 NOTICE OF CLAIM FORM to the City of Saint Paul;Min�d�� Minnesota State Statz�te 466.05 states that " ...every person...who claims damages from any municipaliry...shall cause io 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 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 signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15,�YEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL MN 55102 j First Name ;f��,� Middle Initial�/. Last Name " � 7` Company o�Business Name Are You an Insurance Company? /No Yes, Cl i Number? � Street Address / Ciry State � � Zip Code��j�� Daytime Phone(_� - Cell Phone�s� �c�vening Telephone(_� - Date of Accident/Injury or Date Discovered�� r `��7 Time��'—�am/� Please state, in detail, what occurred(happened),and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul o�its employ es are involv d/ar r ponsible r our dama �' / .� ` J �. Please check the box(es)that most closely represent the reason or completing this form:n � G ^ ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow/�Q F �� .IVIy vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plov�-t-1,!,4�� , 7� ❑ My vehicle was wrongfully to wed and/or ticketed ❑ I was injured on City property�' �� r�� ❑ Other type of property damage—please specify �Ct-✓V1�.� ❑ Other type of injury—please specify � In order to process your claim��ou 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 WILL 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 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—please complete this section Were there wimesses to the incident? �es �., . Ur� own (circle) ' Pro ide their names, ddresses and tel hone numbers: ' � c ' � � ol- <: r __ Were the police or law enforcement called? Yes �I�fio� Unlmown (circle) If yes,what department or agency? Case#orxeport# Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility, clo�se t lan mar tc. Please be as d tailed as possible. If ec ssary, attach a diagram. ��i ° � � l.r�I�� Please indicate the a t y u are se king in compensatio or what you u �ke tY�e ity to,do to .esolve this,clai ,to your sati fac ion. " � � i � � � � j � Vehicle Claims— lease com lete this sect' n ❑ check box if this secti��on do�s�a�� Your Vehicle: Year� Make Model License late Number State Color Registered Owner.T � Driver of Vehicle- Area Damage �� Q r' �. City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—nlease complete this section ❑ check box if this section does not ap,plv 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 treatrnent? (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 wark? (provide date(s)) Name of your Employer: Address Telephone ❑ Check 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 Print the Name of the Person who Com d this Form: � , Signature of Person Making the Clai • � r• Revised February 20l 1 iteve's Auto World -West Bloom. INVOICE BOBBY a siEVE�s auro WORL 10740 Normandale Bivd. 10i4N NORMANDALE BLVD 164740 ��ooniNCroN nN ssaa� Bloomington, MN. 55437 ssz-eai-ssss 952�gg1-1024 Fax- (952)887-4145 nr.�h��t ��:-zs�izbs92 i.bobb andstevesautoworld.com Term ID: 1122 Y Sale INVOICE Print Date : 09I08/2012 raymond,jea VISA 1998 Oldsmobile -Aurora- XXXXXX�XXXKX83Z3 Lic# : - MN Odometer Irti : 11950 , Entry Method: Swiped Unit# : Ceilular(651) ppprvd: Online Batchu. ��000Z v�n#: ID � 38( . Ref# Cust , . _�� -,� -��. q 14.45�31 , "'� �� , 49i08i12 � at .�*�ti� '� , � , ��,,rs ,�Exten�decl� �� , r� � � � � �. ° � �:�'� .�ure + �i' � '�i�'s�P'' �+lwa.�i&l�d�d�4 ,araelW�fi�eS. ,�v r�3�"+� mount&balance 2�25i6C/16 Keli� Inv#; 00000009 Appr Code: 935$32 o.so so.00 14200057 i 439.84 �rvheel alignemnt buy 3 get 1 freE TOtal; $ Q$b,75 � F � -109.96 � � � (j �� )/�� _ free tire _ ' �;�� ,� f Custumer CoPY � tire disposal � TNANK YOU � �Z.00 , �^�� ! �' td �� ' � � _� __ __._.___.__..__.._..__----------�?° : _ � T �r�y 1 � �� C.� • .� � �' � : --<�'L%:��, — � �., , _._.________._---� � __.. ____. . �, : t `� r � � _ � � � ` ' ' �, � ,. �__�. �,;,r��,��,;� � ... , \,� ;� l,�,i� , � � _ _ , �ii �� y l�C' -__�_._�. /� ��'� c� �� ._. �;-� t;�� C"<L � 9 - I � ) �%�C�� . — Cc�1� i1 L�i s��.��` . t, > �(C�i r� �'GC�,�;1 �i � � a�- �, C� - / « �� \' I `�' / �G(%;�,,,� ' � C' 1& C �T �I 1 f� �� t ��,a Current Esi�mate $aas.�s _ Labor: 12G.00 Org Estimate $486.75 Revisions $o.00_ pa�s; 341.88 Sublet: $0.00 Sub: 461.88 Tax: 24.87 Total: 486.75 Bal Due: $486.75 [Payments- ] , As the owner of this vehicle 1 have authorized these repa►rs I guarantee that the the payment is good&will be good at the time Bobl;y�Steve's:iu:o World depr�sits it. If for any reason it does,��i clear my bank, I hereby willingly give to Bobby&Steve's a security interest in my vehicle&authorize repossession of my vehicle. I further understand that alI costs&repossession,as well as towing&storage will be my responsibility. 1 year 12,000 mile warranty on parts&labor. No warranty when installing customer parts.Warranty work has to be performed in ouDra�op&cannot exceed the original cost. Time Signature Copyright(c)2012 Mitchell Repair Information Company,LLC invhrs 11.18.10 Written By:MYERS,MARK-Technicians:Hosman,James . P8g2'I OF�