Ochsner � � ������V�I�
�AR 2 0 2013
NOTICE OF CLAIM FORM to the City of Saint Pau������
Minnesn�o Slate Sluuile 4G6.05 slnte�,s thr�t " ...rrer����ersnrr...�vho cluirna�dnnui,qes,%rmm�n,v muniripality...shall cnuse to Fie presented tn the
governirt,K hudr n�tdic i�nuuirrpalit�'�riN�in 1�i0 dri��s n%Ier Ihe alle,�erl lnss nr rn,ji�rr is di.scnvered n no�ice stating Ihe time,plaee,and
circ�irnes!nnc��s tlTeren/,and r6ia•r�rnnmu o/���nn�pensnlinn or nd�ier relrrf dernanded.„
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. '1'he 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'.
SENll COMPLETED FORM ANll OTHER DOCUMENTS TO: CITY CLERK,
15 WF.ST KF,I,LOGG BLVI), 310 CITY HALL, SAINT PAUL, MN 55102
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First Name _�`''\��!��"�___—____ Middle Initial �_ Last Name��.
Company or Business Name____ __—____.__—_------
Are You an ]nsurance Company`? Yes/ 10 If Yes, Cl�iim N�imber?_____
Street Addresti 1���_- ��� ��'e ��;;,`�-��1�" �szt�'
< < .,, ___ -
_. -
_.__ _ ---— --
��.,r.��:�� --- Stat� 5� _._ --Zip Code � `'�d r
Ciry —'..` . _--
—
_ ___ _--
. - ��y _ '���
Daytime Phonc (____ )____ ____Cell Phone Q„��`�).���.��_�`I_ Evening Telephone(�%5 )� _ 1
. � � °�� ,�_ -- ---Time ��� 3� am/ m
Date of Ace�dent/ In�ury or Date Discovered . 1�_�—_--
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you
feel the Ciry oP Saint Yaul or i*ts employees are involved and/e�r responsible for you1r d`amagesl. 1- `�p`'``' ``��°�^'
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•.w,•� ` "Mt�i ._�_ .A'�ctt �� --- - _'."�-- - _
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Please check the box(es) that most�closely represent the re�son lor comp]eting'this form: U
❑ My vehicic w<�s da�7�aged in an accident ❑ My vehic:e was�amag:,3 u;.r:ng u tov.
■ My vehicle wus damaged by a pothol� 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 specil'y .______________ --..------
❑Other type of injury—please specify _____—______-------_ ---
In order to process your claim you need to inelude copies of all applicable documents.
For the claimti types listed helow, please he s�rre to include the documents indicated or it will delay the handling of
your claim. Documents WII_L NOT be returned and become the property of the City. You are encouraged to keep a
copy for yoursclf before submitting yuur claim form.
O Pre�perty damage claims to a vehicle: two e�timates for the repairs to your vehicle if the damage exeeeds
$500.00: or the actu�il bills andlor rereiptti lor the repairti
O "I'uwing claims: legihle copics of any ticket issUed�nd .+copy of the impound lot receipt
O Other property damage claim�: two repair estimates it the damage exceeds $500.00; or the actual bills
and/or receipts for th� repairs; detailed list uP damaged items
O Injury claims: me;dical bills,i-eceipts
O Photographs are always welcc�me to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please complete this section �
Were there wimesses to the incident'? Yes No rUnknown (cir�e) a �� c���j(jQ�.��$_��(.,�1'
�— Cw.�..�`� �_�3�.i `j `J� �)'�;.�..�
Provide their names, aeidresses and telephone numhers: �� __ ` �,, ��;i�
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Were the police or law enforcement called? Yes �� No Unknown (circle)
If yes, what department or agency?________—__.__--__-- _ Case#or report#
Where did the accidern or injury Cake. place?_Provide street address,cross streel, intersection, name of park or facility,
closest landmark, etc. Please be as dctailed as possihle. If necessary,attach a diagram. �-������w�°� �`��- ""'`
�.� ri,� �,��.,,� �z� 4- i:.� ��.,..� A�L ., � W L �\�SC� �C-���,
-- ---- _------ -- —
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Please indic�te the amoGnt you are sceking in compensation or what you would like ihe City to du to reso�ve i�is c?aim
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to your saUsfact�on. _ �5'-�--�a�__z�__�;__...—.__---------__-- ------
Vehicle Claims- leuse com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year �c�l�`� Make hzyr����c ____ Modc,l____t�`h_�_ _
License Plate N�nnber_3��'1�'�__- Statc. Jfl_Color_ <.-����'�•L� L`'^"
_ ,
Registered Owner M•�1�`•:.a _��,�5.'!�"_.�--------.--
. �
Dnver of Vehicle��ih � __Q��"�nL_—. -------------
-------__.�,.�c•_ _� �.� � •-�r �j�`•Z
'�°' ---- — ----
City Vehicle: Year llamaged_. --M��ke .-----..____ - --Model_.._------
Liceme, Plate Numbcr_-----.----- State.--Color-
Driver of Vehicle (Ciry I�mployee's Name)___ _ —
Area Damagcd----_-----------------
IniurYClaimS plea5t completc this ticction f2$check box if this section does not applv
How were you injured?_------.------------ --- —
-- --_____._._
------- - - ----
What part(s) of your b�+�1y were in�urcd'?---_____._ --- -------------
_----- ---— ------------—-----
-- -
Have you sought medical treatment? Yes No Planning to Seek Treatment(circ e)
When did you receive trcatment? _____.__.— .-___--__----- (provide date(s))
Name of Medical Provider(s):--.-------------------------- Telephone
Address_----- ----- --
------------ - ------- —
Did you miss work as a result oti your-inj��ry? Yes No
. (provide date(s))
When did you m�ss work? -------------- -------------
Name of your Employer: ------------- - ____-------------
Telephone_.__ —
Address----- -- ---------_---------_____-_----- --------.
{$Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this for�n,you are stnl�ing that ctl!information you have provicled is true and correct to the best
of your knowledge. Unsigned forrns will not be proeessed.
Submitting a false claim can result in prosecution. Date form was completed
3-�a-��,3
�nt.a �\, \ �s,��,.
Print the Name oi'the Yerson who Completed this Form: __./-\°��--._ `�'��
Signature of Person Making the Claim: __��.---�---------
Revised Februar�'`_'l11 I
Walr�art :':..
Save money.Live better. �
... . . .. ...t ,612. ).788.-.1303.. . . . . . . . .
•.. . MANAGER.RON.LOPEZ.... . . . . . . .
... . .. . .3800.SILVER.LAKE.RD.NE. .. . . . . .
.MINNEAPOLIS.MN.55421. . . .. . . ..
ST�.3404.OP�.00002371.TE�.90.TR�.09821
- • •.. . ... .. .TLE.ITEMS.FOLLOIJ.. .. . . . . . . .
ORDER.NUMBER.0048570057465
AUTO.TIRES., .069766211459, .. .. .7q.50.X
• FLAT.REPAIR..00787�224338. . ... .10.00.N
, TIRE.FEE. ....000003700848.. . ... .1.50.0
LIFE.WHL.BAL.00787�{224343. . .. .. .B.00.N
HP,VAVLE.STM.060538862039, . . .. . .3.00,X
•. �•.... . .TLE.ITEMS.COMPLETE. . .
••• ••••• . SUBTOTAL. . .. .97.00. .
.... . .. ..TRX.1...7.125.%... . . .5.52. .
... .. . .. . . ... .. .TOTAL... .102.52. .
. ... . .. � . .. . .. . .VISA, .TEND. ...102.52. .
ACCOUNT.#, .., , ..****.��*�r.***�.9512. .S
APPROVAL.#.652820
REF.�t.30690051$395
TRANS.ID.-,163069669285453
VALIDATION.-.76GT
PAYMENT.SERVICE.-.E
TERMINAL.#.13002517
, .... ...03/10/13.. , ..13:36:21. . . . . . . . .
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, ..TC�.993T.597Z.1533.6875.4587.6. . . .
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. , ... . ..03/10/13. ,., .13:36:21, .... . . . .
•. . .. . .. ,***CUSTOMER.COPY+�+��.. .... . . . .
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� ��� WAI,MART#03404
3800 SILVER LAKE RD NE
rir� � Lube �x 1'�SS MINNEAPOLIS, MN 55421-0000 US
� (612)788-1303
� �-,, LIC#MLN913
Service Order:
wwwa oodr ear com�o re r s�err our tiresd or visit
DATE NAME PHONE# 485700 57465
03-IO-2013 OCHSNER,MATT ABERDEEN,MN 57401 (605)290-1734
YEAR MAKE MODEL COLOR
LICENS� - OoUME'fER - CU�Si O�1 i�ARRj�ML TIME, �SERi!��E i OMP 2�MD TIME
— --- -- - ----:---� ------�---------------
Se�vic.c, Descri tion Service
NEW IIRE W'hite��all-IN 0.00
-Ne���Tire- Pass Rcar-COMPLC"TE
-p(1� Nun�her- Pass Rear- PJCIVNEIR341?
FI.A"i RFP��IR I'LIBGLF.SS I0,00
- flal Repair-Pass Rear-COMNLETf
i�IRF.HAIILf�IZ PEE I.50
- Dispose Tire Acceplyd-Pass Rear-C'OMPLETE
WHF:61�[3ALANC'F I_IP1=: R.00
-Valve titrm-Pass Rear-CUMPLETE -Balance Accepted-Pass Rear-COMPLETE
LI IG TORQUG �
Pass Rear 10O FT-LB
Merchandise Description Quantity Unit Price Merchandise
?OS/GSR I S 94T XTRAC2 I ?�1.50 74.50
; I 1/4 HP VS PACKAGE I 3.00 3.00
I
I
, I do agree and f'ully m�de�x�and thai my mutor
. � vehicle had a bw uil Ievel when 1 bruugh� �i lu
W'al-Man fin au vi!chaiige.-Il�is was��intrd out!i�
�, me,Oiat I willinglv requesteA �1'al-Mart io ch:mgc
the oil. I will not holA\4'al-Mart responsible for nnv
damage to my molor vehicle by the Imv oil level.
I
c�,�<<,�»��c�,�»�„�„« Total (Excluding Tax&Govt. Fees) 97.oU
! r��i,�,���.��,c����„�„�„i, DISCLAIMER
I hereAy awhorize the st:ilcd repair work to he douc along with the necessary material,
, nnd hereby gr.mt Wal-Mart pennission to opente�he vehicle herein described on streets,
', highways or elscwhere for the purpose of testing and/or ins�xGion.Au espress
, mechanic's licn is hereby acknowledged ou above vehicle to secure the amount of SIGNED
repairs tliereto. l4'al-A1art is not responsible 1'or loss or damagc to vchicle or articles .
, left in vehicles in case of tire,dieR or any other cause beyrnid W'aI-�9art's control.
1 w�ders�and Wal-A1art did nM inspect my tires fur safely. \Val-Mart only:
� . (I I�'isually reviewcd�he tires for condi�ions obvious to the naked eye and in plain -
- sighi;(?�Measured[read deplh in a�ly one place on each tire with a device that DATE
provides no exact mcnsuremeN:and(1)ChcckeA and adjusted(if necessary)air �
pressuro. 7'he Iread dep�h may not be lhe same at all places on a lire. Driving
condilions will affect fhe safe�y�anJ{n:rfornumce ol'my tires. QUALIT\'CONTROL TFCH:NSONA 2299
SERV WRTR/GREF,TER:NSONA 229��
THIRD QC TECH:UONALD 2J32
���l��-T.��i,.��°,-- TIRE TECHNICIAN:DONALD 2332
03-I 0-2013
� --------------�__------------------ -
- - - � C l!STOtiiER SIGNA"TUR[------ DATE
HAVE YOUR LUG NU"I'S RETORQUED AF"I'ER THE FIRS'I' S0 MILLS.