Peterson-Meyerson ___ _ _
NOTICE OF CLAIM FORM 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 1$0 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to ezplain your claim,and the amount of compensation being requested. You will receive a
written acknowiedgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND O�HER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 ITY HALL, SAINT PAUL, MN 55102
. # }� � _ c
First Name � ' �`LJ ' Middle Initial �� Last Name , �}- �% �� "?
Company or Business Name
. _ -�. - _.. �
Are You an Insurance Company? es o ��Yes, Cl�imNumber?
Street Address � � rt� ��
City �;tiYl���� State �.) Zi Code '-� ,��'�
_� P
Daytime Phone (�ll�'J-�ell Phone ��-�- ��2-1 Evening Telephone����- 3 ��i
Date of Accident/Injury or Date Discovered �C)Y) 1� x•t.t.� ''�.J Time vv���am pm
. . . . �
Please state,in deta.il,what occurred(happened), and why you are submitting a claim. Please mdicate why or how you
feel the City of Saint Paul or its ployees are inv lved and/or responsible for your,d��_ a$es.
S v"Yr G • UV�LSr,�� � �� nd �
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Pl e c e th o es)�at ost clo ly re rese�tfi�easo o��o�ri p mg �s�form:
� My vehicle was damaged in an accident My vehicle was damaged during a tow I
�VIy vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
,-_ ._. , . � � t wed and/or ticketed ❑ I was injured on City property
:;��� .. -�,; .
er o properry _ .�- __ , .
� 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
you�claim. Documents WII,L NOTbe 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 dama ge 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
�6
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. _ _
. _ _ _ _ _
_ __ . _ _
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-ulease complete this section �
Were there witnesses to the incident? Yes �� Unlrnown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unlrnown (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. P��,se be as detailed as possible. I necessary, attac a diagr
� � N � ,� /Ce � QGZJ' � �
Please indicate the amount you are seela,,n�nin c mpensation or what you w th��.y to do to resol�this claim
to your satisfaction. '�,.� t����=/�-� /�� ��'���-� � • ��� ""�"'
Vehicle Claims- lease com lete th9s section
Your Vehicle: Year___�g_�'�Make �;!�i/�Sti/IL�"�odel � - , Gt
License Plate Number -�-State 1'1'1 Color Y t ih�G�
Registered Owner � -
Driver of Vehicl .�� - n�'�''Y�'1
Area Damaged � �cc.) �i. ' - � �WIC��"-
City Vehicle: Year Make Model ,�
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims �lease comulete this section check box if this section does not apnlv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treahnent(circle)
� rovide date s
When did you receive treatment. �P � ))
' Name of Medical Provider(s):
Address Telephone
I Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
T ..- . ._ .. , . ..
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.
l Y1�
Submitting a false claim can result in prosecution. Date form was completed �(,(�S• ',I�C/]��i 2�U�
Print the Name of the Person who Completed this Form:. ��-U� �
Signature of Person Making the Claim:
Revised February 2011
_- * INVOICE * #318856
: TIRES PLUS
1331 W. LARPENTEUR AVENi7E TIME IN/Ap•T:
ROSEVILLE, MN 55113 D� TIME:
PH. 651-645-5409
roseville@knapquist.com WAITING / DROP OFF
www. tiresplusminn.com
�
—Sold To:
"-� ACCOUNT#: 301445
CHARI,IE MEYERSON
1676 LAFOND AVE
SAINT PAUL, MN 55104 DATE : 05/20/13
Ph: (651)336-7163 INVO2CE #: 318856
2013 CARRY IN FLAT REPAIR Billed By: SALE3
Salesman : LEON WILSON S#:2 Rt:
Mileage: �x:Y EX#:
VIN#: N/A KID#: N/A Ct:R COD: IWS:
Parking Space#:
Unit Extended
Quantity Product # Size/Description/Mfr# TC MC DP BIN� Price F.E.i, Amount
• & Vehicle Inspection. g Z
� �� All I,ifetime services above are based 4 Z
• on 2/32nds tread depth of the tire. 4 Z
• �� Tires Plus requires retourquing of lug 4 Z
• nuts on alloy wheels within 50-100 miles 4 Z
• after the removal of the wheel from the 4 Z
• vehicle, 4 Z
Merchandise Services 6 Other F,E.TT' Subtotal Sales Tax Total
71.99 18.98 0.00 90.97 5.13 96.10
Comments: Terms: P0� DUE DATE AMT. DUE Misc. Adj. , . , , , . , $ 0.00
Cash or Gheck �: $ 0.00
Credit Card. . : DI . . $ 96.10
Balance. . . . . C . . , $ 0.00
Received By: « Page 2 of 2 »
Started: 05/20/13 3:55 PM Promised: Completed: 05/20/13 7:46 PM
* INVOICE * #318856
TIRES PLUS TIME IN/APT:
1331 W. LARPENTEUR AVENUE DUE TIME:
ROSEVILLE, MN 55113
PH. 651-645-5409 WAITING
roseville@knapquist.com / DROP OFF
www.tiresplusminn.com
�
-Sold To: �" ACCOUNT#:t301445
. �-'`�
CHARLIE MEYERSON ;
1676 LAFOND AVE DATE : OS/20/13
SAINT PAUL, MN 55104
Ph: (651)336-7163 INVOICE #: 318856
Billed By: SALE3
2013 CARRY IN FLAT REPAIR Salesman : LEON WILSON S#:2 Rt:
Mileage: Tx:Y EX#: Ct:R COD: IWS:
VIN#: N/A KID#: N/A Parking Space#:
',:i} 8t te.ded�
Quantrty Produc't � Size%Descxiption/Mfr� TC MC DP BIN# Price F.E.T. Amount
T101 STANDARD FLAT REPAIR 4 V
. Clean and seal bead 9 Z
. Balance tire & wheel 4 Z
. Problem Found Was 4 Z
. 4 Z
: 4 Z
. Circle Which Tire Needs Repair 4 Z
, t+►+tt+++►�tz�+�++ta++t�+��+,r�;t+�� 4 Z
. Driv/Front Pass/Front 9 Z
. Driv/Rear Pass/Rear 9 Z
, �t��++#+t�+#�+�++�+�+�+++;�+t�++�++ 4 Z
. Tires Plus requires retorquinq of lugs 4 Z
. nuts on alloy wheels within 50-�00 miles 4 Z
. of any service involving the removal of 4 Z
. wheels from vehicle. 4 Z
, �+��+�++;rt�+;r;r+��+++��+����++�;rr+++�+�+++� 4 Z
. CARRY IN 4 Z
, �t���++�t�+��t�,r�►�+��+���++�+t,rtt�+t+t++� g Z
1.0 97000072 P195/60R14 CAPITOL BW SPORT 86H 1 4 69.00 69.00
1.0 VSTM+ PARTS VALVE STEM 1 9 D NO CHARGE!
1.0 TRF FEE TIRE RECYCLE FEE 9 R 2.99 2.99
440-MB DISMOUNT 6 MOUNT TTR$ 4 ?� h'!1 ^��r^-F!
SHOPSUPYLY SHOP SUPPLY TIRE F'r�E 1 9 E Z•99
. Dismount tire from wheel. Clean and 4 Z
. inspect bead of wheel. Install new 9 Z
. valve stem. Inflate to proper PSI. 4 Z
400-2IB LIFETIt� BALANCE 4 W 15.99
. Remove wheel, computer spin balance. 4 Z
. Torque lug nuts to manufacturer's specs. 4 Z
. �� Free Lifetime Flat Repairs, Tire 4 Z
. Rotations, Wheel Alignment Check, 9 Z
Received By: « Page 1 of 2 »
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