Rysgaard (2) NOTICE OF CLAIM FORM to the City of St. Paul, Minnesota, 2 extra pages added to
standard document provided.
I am Robert Alan Rysgaard. I was driving to a Hudson Wisconsin business
appointment on Tuesday March 19th 2013 when this accident occurred. I had
stopped and ate lunch at the Culver's restaurant in the Sun Ray Shopping Center. I
was on my way to Hwy 94 East via the frontage road on Old Hudson Road in front
of the Cub Foods, 2197 Old Hudson Road when I hit a gigantic pot hole which
resulted in a shredded right front tire, a bent right front rim and damage to the
right front tire sensor. This resulted in having to have my car towed, rent a car
from Enterprise and having all the repairs done which are detailed in the repair
receipt performed by R.M.F. Auto Service enclosed with this claim. My tires, rim
and tire sensor were all in fine condition and fully operational with no issues prior
to hitting this pot hole. All these damages were as a direct result of hitting this pot
hole. This pot hole was situated on the frontage road in front of the Cub Foods
store parking lot on Old Hudson Road. There is no excuse for this hazard to have
been blatantly ignored and neglected by the City of St. Paul endangering the
physical safety of the drivers as well as their vehicles. I phoned in and spoke with
the City Clerk who directed me to the website to obtain a copy of the claim form
and also gave me the name (Sandra Bodensteiner) and number (651-266-8887) of
the City Attorney who handles these claims. I called the Sandra Bodensteiner and
gave her the address of the pot hole and explained what happened. I went back
to the scene of the accident the next day on 3-20-13 and took a picture of it with
my cell phone. When I returned to R.M.F. Auto Service to get my car when it was
finished on 3-27-13 I again stopped at the scene and took another picture of the
pot hole and measured it with a tape measure. The pot hole had been filled in.
The distance across the asphalt was 3� x 39 . Braden Adams of R.M.F. Auto
'l, and'stated that b the size of the hole,
Service also went to look at the pot hd e Y
he was astounded that it didn't cause much more damage to my vehicle. Clearly
this repair to the road should have been done prior to my becoming a victim of
the neglect and negligence by the City of St. Paul. My car repairs came to
$1700.00, tow was $21.43, and the rental car was $21.57, so I am asking to be
compensated for $1743.00 I am making this claim to be restored back to my
original condition prior to hitting this pot hole. I am not being opportunistic and
attempting to make money at the expense of this City of St. Paul. All of my claims
are legitimate and documented both by witnesses as wetl as documents I
submitted verifying my claims. I have experienced lower back pain since this
accident and have been treated by my Chiropractor Dr. Barry Bicanich of Prospect
Park Chiropractic on one occasion and I am hopeful that I willed be healed in the
near future and at this time I am not seeking any damages for injuries suffered as
a result of this accident.
�. � 5s� s�r��u� E�n►acE � : oo��rr
Htuls�on, WI 54016 �
715-386-8100 Da�e:�IZ7M3
Cee�er: 1 Pa�e 1 af 2
THANK YOU FOR YOI�BUS'INESS!
Cusbon�er: RYS�GAARD, ROBERT Vehicle: 2001 AUDI TT
Addross: 4322 SHORELINE DR Lice�'�se: �=
Cih►: ROBBINSQALE, MN 55422- VMI : TRUUT28N611003877
Ho�e : ( 612 ) - �: En�ne: 4-1781 1.8L DOHC Tra�+s:
Csll : ( 763 ) 355-44`�l Ext: i�Nap�: 150359 Sub:
Op T�eh � labor Parls SnbblN
OiNn PaR Nwwb�r PaR D�on ' R�on h�►R�pMo�R Prkx—
Servite Req�:
sYre�dc�a flreet dre rar�rair�s foet��ery�bt be�C'
Plare i�k eaf�e vc�de a�i adme
BR3CD3 DN Brtlrt S�stta E�al�tie� . 0.00
TS 00 D11 MniJ1VT AND B�AI.ANCE 411RES 60.00 1076.08 1138.Oa
4.00 100021277 EAGLE GT 54U.60
4.00 TIRE DISPOSAL 12.00
Tread Depth: 10 Warranty: 0
Rating: V Size: 225/45R17
4.00 .VST TIRE VALVE STEM 2.52
4.00 WEIGHT fiEIEEL WEIGHT 7.96
1.00 8N06U1025HZ33 wHEEL 515.00
BRl[90 DN Ae�eve�ReNaoe Ab 3pced Se�ser-Frnat,Ore 286.81 168.99 457.80
1.00 6N0927903C HARNESS 168.99
tay�eNs:
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OK �d I�oo�nd�tloA QIC dtd � OK !!�d � ---
3P17/20'131:41:N Buooe�ul tra Au�: 2�0 MF 0�753Z
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i e09..90 wst *`�"'�""es11 ��RYSG�AARD Aproes!o P�r TaeM M�oa+t Aooael'n0 to Csd MpMr Agw�
"Mdor Vabcle repar Frr�o���b9�ATCP 132,Wis.Adr.Co�e, ad�iislered bf'�e H�rau c#'Cooa�oar Pmkr,eio�, L�O1'' ��{$.$�
w���-�,�;,�,T�,�a c�a Ra�p.,p.o.�asi i,�.,w���ss�oss9i�- Pa�ls: s1.247.07
we..ura�at eer repsir�ra a.a hbOr for IZ.e.tb or 12,eM�ite#,�ic�evcr ooses lat,.vtA� sublst• 30.00
oerlxir e:c�pEie�.l�p�ar+e e:espt Detailt ate araiWtble opi req�est. p�Fess: 50.00
Customer ageees to:1.Pay all oollectiam oostg and/or atto�aey's fees in the errent defgult is made ia�Y P8Ym�t due.
2.If��oa�obik is ret�uaed to cu�oma witbFrt repair service being Perfarmed,a di�gno�tic�d�dling f�ee St+op SuPP�� 515.49
(�ct�g�i�g)mar be c�•3.c�s tett athx wodc is�ed may be s�jed to a�fee.a. St�o�l: a1,611.37
Tams�e Cash,� hav�e boen made pciac to su�ori�tion. g�1es Ta�c: 388.63
I have read and�d d�above aad acimawledge raceipt of�estimste,r�ei�pt of ti�e
merchandise and services set foith h�and a oopy of ii�is sales invoice. patd e�r: Total: �1,700.00
Custoinec' Ca�h
Signa_+�� � � w�r rr+.�: �d: 51,700.00
Thank you fior�our business. We�preciate it! o�: sQ.00
�
. � ; 592 Sc�homn,�e+,D� INYOICE # : 0033327
H�, wi �o�s �� ��
715-386-8100 Da1�:3t27N3
Cen�r: 1 Pape Z o�f 2
TNANIC YOt1 FOR YOI�t BUSINESS!
C�r: RYSC'AARD, ROBERT VehicN: 2001 AUDI TT
Addre�s: 4322 SH�RELINE DR Li�e: �:
C�►: ROBBiNSDALE, MN 55422- 1lMi : TRUUT2�16110Q3877
1�ome : ( 612 ) - �: Enpine: 41781 1.8L DOHC Trans:
CaN : � 763 ) 355-4454 Ext: M�: 150359 _ S�+b: _ —
Op Ted+ Orse�e�n L.�bor Parts Sublotd
tlu�n PaR lluw�ber Part Dwai�lion Rw�on for R�pl�aw�t _ Prk� _
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�t3't/Z0'131:N:49 Bucossdul tra /uRh: ?A90 Rs1: 04753Z
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i lOtAO Wrt �11 RpgERT RYSGAARD�pses b Ray Told MnourR A000�b CMd 1�Ap�M�wnt
�v���n��r���is�,v�.�.ccaa�, .�a�rm���ca..�r+�., ta�or• �345.81
w�emain De�.of'AgiwdO�,TzaAe.a coa.o.er Rwecdaa.r.o.eaec a911,Madi�oo,Ti+'ncoa�.ss7o6-8911� p�1Pl�• S�,2�17.07
We�rurat o�r r+qair p�rts�lab�r for 12�ar 12,lM�r,w�Yic4�.wer e�s 1�,w�i g�- �p.00
ecrl�e:oe�tioes.M�et�a�P�'a m ez�pt.D�t aM'e ava�abk�oa r�- p�pr Fe�s: 50.00
Cuata�er a�ces to:1.Pay all collection oosts�d/a�or�y's fees in th�e evrot default is mede in anY paymeat due-
2.If m�omobik is redaaed to custc�n►er wit2�out�r seavice being perfamod,a dis�c�d haodlin8 fee Slf�fp 8tlpp�es: s 15.48
c���►���y��.3.���,,,��������«*�a��.4. s�r�.�: a,,611.37
Tams are e,ash,���'e been made pr�r w s�Rho�iz�ion. 8�iss Tax: 388-63
I have re�d and unclerstand the above and aclmawiedge recei�pt of an estim�e,receiPt of t�e
merchandise and seivices set forth hec+eia�d a copy af tilis sales invoice• Paia sy: T�1: $1,700.00
S�t�x � �: Paid: 51,700.00
Thank you for your�si�s.s. We appreaate it! o�: �o.00
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Page 1 of 1
ENTE�LEASIN6 COM►ANY,2101�OUt,EE 1�,Mt1D60l1,11YI S�Oi691s0(715)377-l220
I�NTAL A6RKMEMT REf# St1MMARY OF p4ARCES
748393 4RMK9M
Chsrts D�+ D�a��, QMawfltY ►K Ra�a Tohl
REPfTER TIME�DISTANCE 03/19-03/20 1 DAY ;30.00 530.00
RYSGAARD,ROBERT pyy � 03{19-03/20 1 DAY �14.99 ;14.99
pqi � Q3l19-03/20 1 DAY 53.00 53.00
���n�� R1EL SERYiCE OI'i'ION � 03/19-03I20 �2.01
03/39/2013 03:57 PM � �Ap
DATE�TIME IN .�..�., , ••��••
03/20/2013 03:00 PM Tu�t�
SALES TAX 03/19-03/20 5.5% ;2.50
����� TAX�REGISTRATION 03/19-03J20 1 DAY ;0.57 ;0.57
24HOUR RECOVERY FEE
WISOONSIN RfNTAI TAX� 03/19-03/20 5% 52.28
VEN�1 2013 DOD6 QCAR SXT � TOtal tl�#+O�s: l.fS.3S
VIN# 2C4RDGCG1DR524699 NY-7o/t�MOli�s �j �
LIC# 593ZXD iy!!Np DTf�CT SILL**
MIlES DRIVfN 106 TIME&DiSTAPKE 03/19-03/20 1 DAY
SALES TAX 03/19-03/20 1 PERCENT 5.5%
S��� ** TAX®ISTR/1TIOM 03/19-03/20 1 DAII
1949 h0 DIRECT Bil1 (�(bVERY FEE
��� � WISCONSIN RENTAI TAX 03/19-03j20 1 PERCENT 5�16
2775 BLUf WATERS RD SYIibOt�i: (i33•7S)
EAGAN, M{J 55121
Total Aw�o�nt Due �.00
q.AIM IMFO
SHOP: RMF AUTO SERVICE PA��Ip�A�
PHQNE: (715) 386-8100 RM��'up n� CItEDiT CJ1RD MU1�iHt
ATTN: UNKIVOWN $21.5� Mastercard x�000000c�oocx8811 PENDING
3/20/2013
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