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Pflipsen
P NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesotn State Statute 466.05 states that"...every person...who cJaims damages frorn any municipaliry...shaU cause to be presented to the governing body of the municipality within 180 days after the al/eged loss or injury is discovered a notice stating the time,pbce,and circumstances theirof,and the amount of compensadon or other relief demanded." Please complete this form in its entlrety by dearly typing or pcinting your answer to each qnestion. If more space is needed,attach additional sheets. Please note that yon will not be contacted by telephone to darify answers,so provide as much informatlon as necessary to ezplain your daim,and We amount of compeusadon being requested. You�vill receive a written aclmowledgement once yoar form is received. The process can take up to ten weeks or longer depending on the nat�re of your dsim. This form must be signed,and bom pages completed. If something dces 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 J� Middle Initial�Last Name ����5�� Company or Business Name E I VE D Are You an Insurance Company? Yes/No If Yes,Claim Number? APR 3 0 2013 Street Address �3o�s vId i�;a�,w� 8 #1 � ��TY ��RK City�0�`_S�V 1 �� State �� Zip Code 5s 1 l �3 Daytime Phone��' S �Cell Phone(��-�Evening Telephone(_J - Date of Accidend Injury or Date Discovered y' ZU - �:� Time�`��pm Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how you feel the Ci;y of Saint Pau�l o,r�its emplo ees are involved and/or res�nsible for your damages. � W AS u 6 • y S I�J A.► � �0 J� v � ��� '�' ` 0. y v� � . w ,t,� �,J�✓ �. � �. 1� o � � o (�s..F. �� � Please check the boz(es)that most closely represent the reason for completing this form: u��at��c ❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow p�� �My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow My vehiele was wrongfully Eowed and/or�ieketed �I�+as injwed on City property ❑Other type of pmperty damage—please specify O Other type of injury—please specify In order to process your claim vou nced indude cooies of all auplicable documents. For the claims types listed below,please be sure to inclu�le the documents indicated or it will delay the handling of your claim. Documents WQ.L 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 Propedy 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 suppod your claim but will not be retumed. Page 1 of 2—Please complete and return both pages of Claim Form � Faulnre to complete and retnrn both pages will resnit in delay in the handling of your claim. All Claims-ulease complete this section Were there witnesses to the incident? Yes No nknown (circle) Provide their names,addresses and telephone�umbers: Were the police or law enforcement called? Yes No Unknown (circle) ff yes,what department or agency? Case#or report# N�A- Where ciid the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please e as detailed as possible. If necessary,attach a diagram. �C,XIV�.:r� V1� Q,Vk-VJGl�1 G.rC �. Please indicate the amount you are seeki�g in compensation or what you would like the City to da to resolve this claim to your satisfaction. _��o��- `'�� Vehicle Claims- lease com lete this seclion ❑check box if this section does not a 1 Your Vehicle: Year OO U Make �r D �" Model_ Y� W1 License Plate Number State f lI� CoIor Reg'tstered Owner t� � � Driver of Vehicle 0 Area Damaged � v � a-e- ��'� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged ?�iurv Claims Dlease comDlete tlils sectlon ��heck box if this section does not anvlv 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 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�re attaching more pages to tlils claim form. Number of additional pages�. By sigrting this form,you are stat�ing that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be pro�essed 3ubmilting a false claim can result in prosecution. Date form was completed Print the Name of the Petson who Completed this Form: S, 1 u��tit 'Q�� .. Signature of Person Ma�ng ffie Claim: Revised February ZOi l (,cor.� �r� C��iw� ,.�ov�w,> . ' � SOY'�lr2tSY�Q. _ ,.Y��k�l C�Y-C,C�. � � '��--C�1'►''4-� l,�.l�C c�W C�-�rY�-�.C� �;�n.d�. • i Y��►�'��. � .. �-�e. 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' � ' + . . � � . - • � • • " , • ' . • ` , '. I M25/13 �rrgil-Irrreges in"" . �`, � �^,- �. �� x ����'�� ��t,� �� �� �r_ . �-V'$ ��f�.� iyn .. y 'i`-E`'". �� a � rw • z�_� ..<.,�,_ -.:W.� ���1� y�,,_� �� : . ._.... ._ ' '"'..'., "rW.�.. . ..��.—�.�—. � ��e lPeg � httpsJ/mail-attadxr�ent.googleusercartent. '=2&ilFe1eP3d9a1a8�uev�att81F�13e4.34e�40f7cP1ab&d�sp�imgs8saduie=AG9B P�g-2oCc2h... 5J6 � . s • r • . • • • r 4/25113 Gmail-Irrrages in"" ��_ � X- .. !.. 1'.. _ . R � e �' 0 � m 4 � f k � a« �. `. t � �. * MtpsJ/rr�ail-attacMrient.googleuserconteM.caNattachrrierd/WQ�'hi=2&ilFeleP3d9a1a&Nev�att&1h=13e434e40f7cYLab8�d�s�imgs8sadui�AG9B PBsg-2oCc2h... 6/6 John's Auto Parts �oHN's :;, - 10506 Central Avenue NE �'?� Blaine, MN 55434 ��� INVOICE# DATE � 763-Z84-1711 Fax 763-784-8132 � 1=ti00-862-4543 .9 1105392 4/20/201310:57 www.johnsauto.com parts@johnsauto.com � G�'O PP�� P.O. NUMBER CUSTOMER# � 1 0 Ken H cash � , 1VI1�1 � MN D p T T O p SALESPERSON ORDER TYPE TAX ID/CODE SHIP VIA PG 1 - l NRW COUNTER SALE MN will-call 1 QTY DESCRIPTION UNIT PRICE EXT. PRICE 1 560-69313 3S-Wheel; Stk#NEW13; F113B043 $49.00 $49.00 R 001480563; NEW AFT BLACK STEEL, 14 VENT HOLES ; Q:1142545; D:335032 90 Days Parts Only Warranty $0.00 $0.00 � '` �4� � ov � � �� �� � � � � m � o, °i � o . ? n � 0 � w i a -- -- � � �, � z pOpo C —� ['� � o r . � a � rn �A '�. • 70 � r�*+ � � � � � � • � v Q i `L' � ' Q � � � �, o I N I 0 0 0 -�; �„ ° ° � ° ° ^' o � � " ° o � � ..o "' � � G � O N O � N O � �� . . � L� O � Ll V V V �i- W �- NOTES i Thank You for our urchase! _. PAYMENT TOTALS PAYMENT NOTES TOTALS CHARGE ,, _ FREIGHT CASH , DlSCOUNT CHECK ' TAXABLE $49.00 CREDIT CARD $52.49 __.� NON TAX $0.00 DEBIT CARD TOTAL TAX 53.49 RECEIVED BY INVOICEAMT � WELCOME TQ MURPHYS SERVICE CENTER ST. ANTHONY, MN 55418 612 781 4489 00000091926-Oi MURPHYS SERVICE 3501 29TH AVE NE ST. ANTNONY MN r ; PC�e►��t Descr__ qty amount �r < DUPLICATE RECEIPT > LABDR 1 15.00 s W j ����`� Sub Tota I 15 00 �� ✓'Q "��'�'► Tax 00 TOTAL 15 . 00 ���-F �j� CREDIT $ , p CARD TYPE: VISA CARD NAME: PFLIPSEN/KENNETH � �/►�i.J ACCT NLIMBER: ************2707 EXP. DATE� TRANS TYPE: SALE �i�,iv� , AUTH# 01394G 00 DOC # 95033 NO SIGNATURE NEEDED TOP COPY - MERCHANT 2ND COPY - CUSTOMER **************************************** Earn up to $ . 25 on Ma ra t I-�on pu rcF-�ases w i th MaratF-�on V i sa **************************************** ', THANKS , COME AGAIN i REG# 0002 CSH# 003 DR# Ot TRAN# 23288 04/20/13 12�07�06 ST# MURPH .���+ �� (�Gt w�a�t� s % �2 ; � ; 5� . y � Lp�OU'� � � �� O � �-.------� - �- ..� ,� q �. � ' .,�" �_.