Dirienzo � RECEIVED
NOTICE OF CLAIM FORM to the City of Saint �au121Vrin�nesota
. .��T��LERK
Minnesota State Statute 466.05 s�tates thnt "...every person...wha claim,s damctges frnm r�n��municr •....ti 1 cau.re tn be presented to the
governdng bod��of the municipality within 180 days after the alleged lo,rs or injury�i,s di.scovered a nntice.rtating the time,place,rarrd
circum,stances thereof,and the a.rrwunt of compensation or nth.er relief demcutded."
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 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ��� Middle Initial� Last Name � ( �l .I�L 2�
Company or Business Name �!A-
Are You an Insurance Company? Ye /No If Yes,Claim Number�
Street Address � Z�O(o �)1J�1��.tQ-1��7 (��fl =
City �YQ—�'►J �L�—� �� State W-�-- Zip Code �� � 'J Z-
Daytime Phone(�)�-�Cell Pho e��-����Evening Telephone( ) -
Date of Accident/Injury or Date Discovered �QGI�9��i 2�'� Time�_am pm
Please state, in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how you
feel th Cit of Saint Paul or its employees are involved and/or res onsib for your damages.
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Please check the box(es)that most closely represent the reason for complehng this form: '
❑ My vehicle 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 in}ured on City prc>p�rty- I
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you need to include coAies of all annlicable documents.
Far 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.
Q'f'roperty damage claims to a vehicle: two estimates far the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts far 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/ar 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- lease com lete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telepho mbers: ,�M/+N✓J� S 0�1'�`-1 P ��a'- $ ��- �`�5�
D�»�e�s,r.-1 �\Ic-� 6E-R,�iJ, vJL
Were the police or law enforcement call d? Yes No Unknown (circle)
If yes, what department or agency? �n��(i. ��57', i��+a-� Case#or report# '
��ST w� �Cl!//>tG �RT � N�E+A=/,� T7�/�'�9i1-kS^//�N G4t/'-�f�t,v4r/fd ha j �FL/�T T�AZ.t .
Where did[he accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. Pl ase be as detailed as possible. If ecess tta h a diagr
Uh G�v�l�.�� �4� �+��w�� � �11 I �5�y /�ve •
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�o� 7�� R�P�'Kt�+c-%t Mo���6 �N�/yr,cfnx.�.ub, Gvsi aF ��
l�F��t m-�NT �l,S i o F r��6NM.E-,�/T �%�iTi7-L -' ��Z�,? �
Vehicle Claims-please complete this section �check box if this section does not applv
Your Vehicle: Year 70/ Z Make Ta7v�'L� Model �'r'��"27
License Plate Number�3 2�- T N 7� State(`,v f Color �s/1-E
Registered Owner US B N 2�E�?� -� d.0 A l�-�'=K�'O
Driver of Vehicle Ft i I G-N�
Area Damaged �brfT t/�,.lT �/� + 7��C i �L.( GrY/�t,Fic!%
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-alease complete this section �check box if this section does not avplv
11/�/F How were you injured?
What part(s)of your body were inj ured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (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 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 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 irt prosecution. Date form was completed �J ' � 7' � 3
Print the Name of the Person who Completed this Form: -� A � t R-1`�� Zv
, �
Signature of Person Making the Claim:
Revised February 2011
: r���R GROv
..� # : 147498
205647 1 �
*�rzvozcE* TOYOTA
�OE DIRIENZO
7266 PINEBERRY RIDGE DUPLICATE 1 1037 Highway 110 � Inver Grove Heights, MN 55077
FRANKLIN, WI 53132 PAGE 1 (6511455-6000
HOME• CONT•414-719-6 4 2 6 www.invergrovetoyota.com
BUS: CELL:414-719-6426 SERVICE ADVISOR: 4240 JILL VARNEY
COLOR YEAR MAKE/MODEL VIN UCENSE MILEAGE IN/OUT TAG
GRAY 12 TOYOTA CAMRY 4T1BF1FK3CU061342 438TNJ 12166 12166 438TN.
DEL. DATE PROD. DATE WARR. EXP. ' PROMISEO ' PO N0. RATE PAYMENT INV. DATE
25FEB12 D 21: 00 13MAR13 CASH 13MAR13
R.O. OPENED REAOY OPTIONS: DLR: 22053 ENG:2 . 5_Liter
I
14 : 05 11MAR13 16: 02 13NIAR13
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
A CUSTOMER REQUESTS A TIRE REPAIR WITH TIRE PATCH ON VEHICLE = '
PASSENGER FRONT TIRE WENT FLAT - IN TRUNK NOW - INSPECT AND
REPAIR OR ADVISE
WH4 MOUNT & BALANCE 1 NEW TIRE ONTO PASSENGER
FRONT - FOUND RIM DAMAGED/BENT AND TIRE
PUNCTURED ON SIDEWALL
4172 CX ' 20 . 00 20 . 00
1 DT001-31674-BS P215/55R17 191 . 00 191. 00 191 .00
1 42611-0675� WHEEL, DISC 378.65 378.65 378 .Fi5 ' '
MS TECH NOTES TIRE TREADS AT 11/32NDS, INCLUDING
- _ _ I
�
4172 CX 0 .00 0 .00 �
PARTS: 569 . 65 LABOR: 2� .00 OTHER: 0 .00 TOTAL LINE A: 589 . 65
***********�****�r*�*****��*'***��r���r***�**`,�********** �
B CUSTOMER REQUESTS A FOUR WHEEL ALIGNMENT
SU1C PERFORMED ALIGNMENT PER<<REQUEST - `POSSIBLE' : -
ALIGNMENT MAY HAVE BEEN CAUSED WITH WHATEVER _ ,
CAUSED RIM/TIRE DAMAGE _
4024 CX 89 . 95 89 .95
PARTS : O. OQ LABOR: 89 . 95 OTHER: 0 . 00 TOTAL: LINE B: 89. 95 '�
********************************************,********
CUSTOMER PAY ENVIRONMENTAL:, DISPOSF.L, AND St1PP�IES, �'EE �`OR: REPAIR ORDER 8:80
THAiNK YO� FOR CHOfJSING THE ALL NEW INVER
" GROVE' TOYOTA� �'OR"YOUR SERVICE NEEDS. �
DESCRtPTt4N TOTALS-
ON BEHALF OF SERVICWG DEALER, I HEREBY CERTIFY THAT THE STATEMENT OF DISCLAIMER - —
INFORMATION CONTAINED HEREON IS ACCURATE UNLESS OTHERWISE The factory warrenty constitutes ail LABOR AMOUNT 1 O 9. 9 5
SHOWN. SERVICES DESCRIBED WERE PERFORMED AT NO CHARGE TO �hetsate ofathiss i e�m\it mseCThe PARTS AMOUNT 569. 65
OWNER.THERE WAS NO INDICATION FROM THE APPEARANCE OF THE Seller hereby expressly disclaims all GAS,OIL,LUBE O . O O
VEHICLE OR OTHERWISE, THAT ANY PART REPAIRED OR REPIACEp ,,,�arra�des either express or
UNDER THIS CIAIM HAD BEEN CONNECTED IN ANY WAY WITH ANY �mp���, (ncluding any implied SUBLET AMOUNT O . O O
ACCIDENT, NEGLIGENCE OR MISUSE. RECORDS SUPPORTING THIS warrantv of inerchantabifity �� MISC.CHARGES H .H O
CLAIM ARE AVAILABIE FOR ll) YEAR FROM THE DATE OF PAYMENT titness for a particular purpose.
NOTIFICATION AT THE SERVICING DEALER FOR 1NSPECTION $Y Setler neither aswmes nm
MANUFACTURER'S REPRESENTATIVE. authorizes any other person to TOTAL CHARGES G$8 .4 O
assume for h any liability m
connection with the saie of this LESS ADJUSTMENTS O. O O
itemfitems. SALES TAX
(StGNED) DEAIER,GENERAL MANAGER OR AUTHORIZEO PERSON tDATEI CUSTOMER SIGNATURE PLEASE PAY `
THIS AMOUNT 72$ . 9 8
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Joe D.
From: "CI-StPaul DSIComplaints [DSIComplaintscLDci.stpaui.mn.us]
Sent: Monday, March 11, 2013 2:43 PM
To: 'muskyjoe@wi.rr.com'
Subject: RE: Online Form Submittal: Ask a Question / Report a Problem
Thank you for contacting the City of Saint Paul.
I have forwarded the information you have provided to the Street Maintenance division of
Public Works to respond. If you do not receive a response in a timely manner please contact
Street Maintenance at 651-266-9700.
Have a great day.
Christine Voyda
City of Saint Paul
Department of Safety and Inspections
Office Assistant III
651-266-8989
-----Original Message-----
From: nc�re I aici_vic�lus.com [mailtc�:noreply�civ_icpll�s.com]
Sent: Saturday, March 09, 2013 9:16 PM
To: *CI-StPaul_DSIComplaints
Subject: Online Form Submittal: Ask a Question / Report a Problem
The following form was submitted via your website: Ask a Question J Report a Problem
Your Name: 7ay Dirienzo
Your Address: UST campus
Phone Number: 414-719-6426
�
Email Address: ��us�;;�;;��e;u���zirrr__com
Please select the category for your concern. : Pothole
Brief Description or Question (or other problem not listed) : Large pot hole. Blew out the
tire on my car. Cleveland ave, between Randolph and Wellessey ave.
Street Address:
Intersecting Street (if applicable):
Describe the location in detail. (eg. behind garage, next to front steps, etc. ) : On
Cleveland, between Randolph and Wellessey
i
�
Additional Information:
Form submitted on: 3/9/2013 9:16:21 PM
Submitted from IP Address: 65.27.48.107
Referrer Page: htt�://vdww.stpaul.�o�f/index.aspx?NID=57
Form Address: htt�;Jltivww;st�aul,g�v/�orms�aspx?FID=65
2