O'Leary �e��.��iV°��
MAY 302013
NOTICE OF CLAIM FOR1V�to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the 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 acknowiedgement 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 O'�HER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �-� L Middle Initial � Last Name ����–��>2'�//
Company or Business Name /V�
Are You an Insurance Company? Yes�If Yes,Claim Number?
Street Address � / �� sA'if/�/1��� ��)!/�
City SI ��� Stat�e /'�Il� ZipCode 5�j� �
Daytime Phone( LZ)� 6[�1� Cell Phone(�O�o1)�-OL d- Evening Telephone(�)�-��`I
Date of Accidend Injury or Date Discovered �fQ-� L �5 .ZU��j Time �Z-U am/�
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 ar its employees are involved and/or responsible for your damages. �00(� ST�T �111Q�naNs-
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check the box(es)t at most closely represent the reason for completing this form:
❑ y vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
y vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed anci/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 vou need to include copies of all auplicable 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-nlease comnlete this section
Were there wirnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No 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,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. O IJ Tli� SuuTN 5110 E
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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. # 2�;.(L�
Vehicle Claims-please comnlete this section ❑ check box if this section does not applv
Your Vehicle: Year 20(?� Make_�912-� F;SCA�D�Model t1T�iV l U/l�
License Plate Number Z.Sy State t�L Color �(,�
Registered Owner "�lf'I 1�1 �. �
Driver of Vehicle �
Area Damaged �_D IJ"T Q1{,�1�4T �PA55�YU Sl � �.�
City Vehicle: Year Make Model
License Plate Number State 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 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
- Wl�en did 3�u�is��uerk? - - _ -- --- - -- ��rQyid�dat�(s)1_—__
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 in prosecution. Date form was compl d /'l 1�� ��� ����J
�
Print the Name of the Person who Completed t ' Form: C ��
Signature of Person Making the Claim:
Revised February 20ll
_ _��__ _.__�_
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���� How d�.d we do? Receive a $10 aff oil change coupon on
your ne�ct visit. Please, camp2ete the survey at
Ttmps*i�awN�feRAlcES•�►tTl�fqas �+Mr.ntbcares.com Use passwprdG'7340768 000as
MN NATL TI�.E e� BAT # 875 * FINAL BILL -INVOICE** Page 1
2185 FORD PKWY Invoice# 6734t3768 - RI
ST PAUL Aql�t' 55116-181.6 Order Num' 40960737 - WI
4651) 690-5007 Date/Time In. . . . . . . . Q4/16j13 10:39:1a
Date/Time PromisecT. . 04/1.6/13 18:49:45
20Q7 CARRYOUT CARRY�UT
Tag: 257JTG St: NII�T Mileage: 1
Engine: VIN# 1�+ICIIOJ92DUA29332
Customer: 3i84�sa� PD#: ------'Ship To: w----------------------------
O'LEARY, FATTY
1910 SUENNERS
ST PAUL MN 55116
t�pening S�lesperson 1296520? Home# 763-293-1252 Worl�#
�mail:
Item Ntzm�aer Item Des�ription------------- -4ty` Price E�:ch �Extended
---------------------------------------
X� C4NTII+TENTAL CONTI FROCONTACT 1 249. 99 249 .99
235 /45 19 V
New
�'Z"r S�RVICE CENTRAL NC INSTALL TP 3.
VS-95`f3 TPMS REPAIR KIT 1
VS-950-TBC
NCb WFiEEL BALANCE N4 CHARC3E 1
KMTSL MOT7NT AN� INSTALL 1
32001262 VANG, XENG PAO
LTRF LIFETZMPs TIRE R4TATE SVC 1
LF`FR LIFETIME FLAT REPAIR SF�RVICE I
MASTERCARD Mast�rCard 269.05_
CARD NUMSER 1422 APPR 01645B
IF Y4U HAVE A QUBSTION �R CQNCERN PL�ASE SPEAK
TO DU'R STORE M2INAGER, WILLIAM PUNCHES
AT (651} 690-5OQ7
Special Credit:
Total Charg�s. . 249.�9
Total Credits. . .0Q
Sub-Total. . . . . . 249.99
New Tire Fees** .QO
Shap Fees (*) .40
AI:l Taxes. . 19.06
Payments. . . . �69.�5-
N�t Amo�zn.t. . . . . .00
PLEASE' PAY ABOVE AMOUNT,
TFiANK Y0II! Claser:12989328
I have received the goads and services as represented on this invoice. Tf this is a cr�dit card
purchase I agree to pay and comply with Lhe cardholders agreement v�ith the issuer. *This aharge
represenLs costs and profits to the vehicle regair facility for misaellaneous Shop Supply or
Waste �ispasal.
Customer Signature
PLEASE SEE ItEVF;RBE SIDE FOR W ARRA:�11'Y>TERMS,CQNI]IT'TONS ANI?QTHETt IMPORTANI'RJFORMATIQN CUSTOMER COPY