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Jones, Billy .,._w>4..� V CL! MAR 2 2 2013 NOTICE OF CLAIM FORM t��t�i� �� Saint Paul, Minnesota Minreesota Stn1e Stahrte 466.05 states that "...every person...w/:o clarms rlamages from any municipality...shall cause to be presented to the governing body of ihe municipality within 180 clays after the alleged loss or injury is discovered a notice stating tlze 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 natnre 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 � ST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name I �� fIJ�J Middle Initial Last Name ��'--� Company or Business Name �� Are You an Insurance Company? Yes/ If Yes, Claim Number? Street Address � 7�� /U� �� City v State � Zip Code��`��? Daytime Phone (��()��Cell Phone (�� )�� ening Telephone (� - / i Date of Accident/Injury or Date Discovered �'��O� � Time�_am 1-��--� 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 or its employees are involved and/or responsible for your damages. _�_�/ -��'- �f b v(1� � ► . � C_�___��,�� Please check the box(es)that most closely represent thie reason for completing this form: ❑ ehicle 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 ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim You 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 witnesses to the incident? Yes �.e� Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enfarcement called? Yes NQ/� 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, clo st andmark, etc. Please be as detailed as poss ble If ne es ary, attach a diagram. �i�P,-i�v �"% �� l �-1��/�a f'�� Please indicate the amo nt y9u are see �ng in com�e ation or y,�h�yoq woul f li�>ke the City to do to resolve this claim to your satisfaction. �� / f � � �" �� Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year�_Make C� Model , License Plate Number State Color Registered Owner� i � l� D '�{�k'`��T�- . ( � Driver of Vehicle Area Damaged / �- City Vehicle: Year Make Model � License Plate Number 70 Y 2 State !S'1 Color � �' Driver of Vehicle(City Employee's Name) Area Damaged In'ur Claims- lease com lete this section ❑ check box if this section does not a 1 How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes Planning to Seek Treatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address lephone Did you miss work as a result of your injury? Yes When did you miss work? (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 sigiziizg tlzis form,you are stating tlaat all i�aformatioiz you liave provided is true and correct to tlie best of your knowledge. U�zsigned forms will not be processed. Submitting a false claifn ca�z result in prosecutiosa. Date form was completed Print the Name of the Person who Compl this Form: � l �� n�� Signature of Person Making the Claim: Revised February 2011 CUSTOMEZ #: 2419177 168151 *INVOICE* � �� • ��. BILLY GENE JONES � 1493 EAST COUNTY ROAD E 545 DESNOYER AVE DUPLICATE 2 WHITE BEAR LAKE, MN 55110 SAINT PAUL, MN 551044917 PAGE 1 PHONE (651) 484-7231 HOME: 651-646-5704 CONT: 651-646-5704 BUS : 651-728-0693 CELL: 651-646-5704 SERVICE ADVISOR: 1866 BRANDON KACHEL _ _ __ _ __ _ _ _ __ _ __ _ _ COLOR " YEAR ; MAKE/MOD�I �/IN I�IGENSE MILEAGE tN!OUT:,; < TAG STERLING 12 FORD FUSION 3FAHPOHA2CR269882 670HYR 7120/7120 ASDF DEL DATE ' PROD.''DATE WARR.:EXP. PROMISED 'PO N0. .; RAT�i; 'PAYMENT INV:DATE 22FEB12 D 20 : 00 18MAR13 Q CASH 18MAR13 R.o. oPErvE� <: REApY ` oPTiotvs: STK:CR269882 DLR:44A121 ENG:2 . 5_Liter TRN:A 14 : 17 18MAR13 15 : 01 18MAR13 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL A Michel.in ENERGY 'SAVER' A S ! (V-RATED ' Part Number 9004 !03458 Type Passenger Size P225/50R17 QMBV1 VEHICLE ,BROUGHT ,IN FROM HITTII�TG A POT HQLE '< AND BLOWING OUT TIRE 2884 CFQ J.5';. 00 15. 00 ' 1 9004*03458* P225/50R17 198 . 95 178.33 178 . 33 1 'DISP�FEE* TIRE DI``SPOSALt 2'.50 ' 2',. 50 < 2'. 50 PARTS : 180 . 83 LABOR: 15 . 00 OTHER: 0 . 00 TOTAL LINE A: 195 . 83 ; , , , 7120 MOUNT>. AND BALANCED`' 1 TIRE CP 30 ', **************************************************** __ _ _ B ENTER DOT CQDES 1 . 2 . 3 : 4 • - DOTS ENTER DOT CODES l. 2 . ! '3 . 4: ' 2884 CF 0 . 00 0 . 00 PARTS : 0 . 0 0 LT-�BOR': 0 .0 0 t�THER': 0 .>0 0 'TO'I'P:L L INE B:: O r.0 0 ' **************************************************** C MULTI-POINT 'YNSPECTION MULTI-A CUSTOMER REQUESTED TO HAVE A MULTI POINT INSPECTION PER�'ORMED THIS VISIT, - 2884 CF 0 . 00 0 . 00 ' Q99P MULTI-POTNT TNSPECTTON' 2884 CF 0 . 00 0 . 00 GTIRE TIRE TREAD DEPTH 'IN GREEN AREA 2884 CF 0 . 00 0 . 00 'GBATT BAT'�'ERY '>TS GOOD ' _ 2884 CF 0 . 00 0 . 00 GBK ,OVER5MM ERAKES REMAIN(DISC)OR 2MM(DRUM) 2884 CF 0 . 00 0 . 00 PARTS: 0 .'00 LASOR': 0 . 00 OTHER: D.00 'TOTAL LTNE C:> 0'. 00 **************************************************** D VEHICLE :!TOWED IN!': _ _ _ V TOW IN COVERED BY FORD 28$4 ' CF' " ' " 0''. 00 ! 0 _00 ` PARTS: 0 . 00 LABOR: 0 . 00 OTH�R• 0 00 TOTAL LINE D: 0 . 00 SERVICE HOURS aUICKLANE HOURS S7ATEMENT OF DISCLAIMER J�pESCRIP710N , TOTALS The factory warranty constitutes all of the LABOR AMOUNT MON. -THUR. MON. -THUR. warranties with respect to the sale of this 7:00 A.M. - 7:00 P.M. 7:00 A.M. - 7:00 P.M. item\items. The Seller hereby expressly pARTS AMOUNT FRIDAY disclaims all warranties either express or FRIDAY implied, including any implied warranty of GAS,OIL, LUBE 7:00 A.M. - 6:00 P.M. 7:00 A.M. -6:00 P.M. merchantability or fitness for a particular SATURDAY purpose.Seller neither assumes nor authorizes SUBLET AMOUNT 7'OO A.M. -4'00 P.M. any other pNrson to assume for it any Iiabiiity MISC.CHARGES • • in connection with the sale of this item/items. ALL PARTS NEW ORIGINAL EQUIPMENT TOTAL CHARGES BODY SHOP HOURS PARTS HOURS UNLESSOTHERWISESPECIFIED LESS INSURANCE MON. - FRI. MON.-FRI. v-RECVC�eo C RECONDITIONED SALES TAX 7:30 A.M. -6:00 P.M. 7:00 A.M. - 6:00 P.M. SATURDAY CUSTOMER SIGNATURE PLEASE PAY 7:30 A.M. -4:00 P.M. X THIS AMOUNT CUSTOMER COPY �G,G�C��K�i ZlQ�G/ CUSTOMEk #: 2419177 168151 *INVOI CE* � �� • ��. BILLY GENE JONES � 1493 EAST COUNTY ROAD E 545 DESNOYER AVE DUPLICATE 2 WHITE BEAR LAKE, MN 55110 SAINT PAUL, MN 551044917 PAGE 2 PHONE (651) 484-7231 HOME: 651-646-5704 CONT: 651-646-5704 BUS: 651-728-0693 CELL: 651-646-5704 SERVICE ADVISOR: 1866 BRANDON KACHEL COLOR Y�AR MA'KE/MQpEI. VIN I.ICENSE MILERGE IN/OUT TAG STERLING 12 FORD FUSION 3FAHPOHA2CR269882 670HYR 7120/7120 ASDF DEL''DA7E PROD;'D,4TE 'WARR.:!EXP, PROMISED PO NO.;> RATE iPAYIv1ENT INV, DATE 22FEB12 D 20: 00 18MAR13 Q CASH 18MAR13 R.O. OPENED REA:pY ' OPTIONS: STK:CR269882 DLR:44A121 ENG:2 . 5 Liter TRN:A I 14 : 17 18MAR13 15 : 01 18MAR13 I LINE OPCODE TECH TYPE HOURS LIST � NET TOTAL CUSTOMER PAY SHOP SUPPLIES 'FOR REPASR ORDER 2 , �p _ _ _ � � _ _ _ � '< _ i � � I ;. _ __ _ _ < i ` ; � _ _ _ _ _ _ _ _ _ _ _ __ _ __ __ __ __ _ _ _ ____ _ .._ _ _ _ _ _ _ _ _ _ _ ___ __ _ _ _ _ _ _ _ ____ __ _ _ _ __ _ _ _ , __ _ _ _ ___ ___ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ __ _ ___ _ _ _ _ SERVICE HOURS QUICKLANE HOURS STATEMENT OF DISCLAIMER D�SCRtPTIpN TOTALS The factory warranty constitutes all of the LABOR AMOUNT MON. -THUR. MON. -THUR. warrenties with respect to the sale of this 7:00 A.M. - 7:00 P.M. 7:00 A.M. - 7:00 P.M. itemutems. The Sei�er hereby express�v pARTS AMOUNT 18Q g3 FRIDAY FRIDAY disclaims all warranties either express or implied, including any implied warranty of GAS,OIL, LUBE � . �� 7:00 A.M. - 6:00 P.M. 7:00 A.M. - 6:00 P.M. merchantability or fitness for a particular SATURDAY purpose.Seller neither assumes nor authorizes SUBLET AMOUNT � . �Q 7'00 A.M. -4:00 P.M. any other parson to assume for it any liability MISC.CHARGES ' in connection with the sale of this item/items. 2 . 7� BODY SHOP HOURS PARTS HOURS ALL PARTS NEW ORIGINAL EQUIPMENT TOTAL CHARGES 198 . 3 UNLESS OTHERWISE SPECIFIED LESS INSURANCE O . O O MON. - FRI. MON. -FRI. u-useo R-REBUILT 7:30 A.M. - 6:00 P.M. 7:00 A.M. - 6:00 P.M. v-ReCVC�eo C-RECONDITIONED SAI.ES TAX SATURDAY CUSTOMER SIGNATURE PLEASE PAY 7:30 A.M. -4:00 P.M. X THIS AMOUNT 41 CUSTOMER COPY �G,G�G��lf�i ZlQ�GI