Donald • •.+v r�i v 60„v
JUN 19 24��
NOTICE OF CLAIM FORM to the City of Sai��ja�a���}�esota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...sball cause to be presented to the
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumsrances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or print�ting 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 aclu�owledgement once your form is received. The process can take np to ten weeks or longer depending on the
nature of your daim. This form must be signed,and both pages completed. If sometlring dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER D4CUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL,Ml� 55102
First Name Middle Initial�Last Na� `Y1Ct.�1�
Company or Business Name
Are You an Insurance Company? �/No ff Yes,Claim Number?
Street Address � �J� �
City Y 1���.`> State �i�.� Zip Code �.J
Daytime Phone�,Q��C��pCell Phone�,Q��-��Evening Telephone��-��
Date of Accidend Injury or Date Discovered Time am/pm
Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please in 'cate why or how you
feel the iry 'nt P ul or its employees are involvec�and/or responsible for your damages. C�'�'1D�
t �
Please check the box(es)that most closely represent the reason for completing this form:
�My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
-�1�1y vehicle was damaged hy a pothole or condition of the saeet ❑My vehicle was damaged by a piow
�O My vehicle was wrongfully towed and/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 you need to include coaies of all aaalicable 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 WII.L NOT be returned and biecome 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 fc.the repairs to your vehicle if the datnage 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 recEip�
O Other property damage claims: two repair e�stimates 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 aze 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 resalt in delay in the handling of your claim.
All Cisims—nlease comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes � 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 fa+cility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
Please indicate the amount you aze seeking in compensation or what you would like the City to do to resolve this claim
to your satisfacrion.
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year�_L2____Make � Model
License Plate Nu State�Y r..�Color
Registered Owner
Driver of Vehicle �°
Area Damaged �
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section ❑check box if tlus section does not avvlv
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 Medicai 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 attach�ng more pages to this cisim form. Nnmber 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.
Submilting a false claim can result in prosecution. D$te form was completed �f ����
Print the Name of We Person who Com � e this Form:-�r�J`-� �'�"�� .
r
Signature of Person Making the Claim: "�-' � �`
Revised February 2011
-----�
� Tires For Less
3011 3rd Ave S � . - .. ■�
Es#imated Minneapolis, MN 55408 ;
rme� �6'2>s25-�99s � Invoice #21536 J
', Saturday, May 18,2013
11:13:43 AM
Helen Donald ;
Ordered on
Saturday,May 18, 2013
Minneapolis MN '
' Workorder#23144
- - MAKE&MODEI _ , PH4N� REP CSH. P�# TERMS
rf tEET IVt).
2000 FORD EXPEDITION XLT �612-423-9198 ATIF SOUSSi AS ' I Cash
LICENSE IVO. MlLES 1N/OUT VIN TORQUE ENGINE SIZE TRAIVSi1AiSStON COLOR ' PRD dATE
URW867 !, 1FMRU1666YLA91228 I ' i � '
CATALOG DESCRIPTION QTY � PARTS LABOR DISC� FET i TOTA
_ —�,. i
L Code ;
IOP LF AXLE —� 1 68.20 , $68.20 AS
OP LF LOWER BALL JOINT 1 29.23 $29.23 AS
SL R&R LF AXLE 1 65.00 $65.00 AS
S� R&R LOWER BALL JOINT 2 65.00 $130.00 AS
i
__ __ . - - ._---------- —
---
Welcome, We appreciate your business.
_. _ —_ _ _.._
PAID BY Parts $97.43 Taxable $97•43 !
MIC$300.01 Labor $195.00 Non-Taxable $195.00
Freight $0.00 Locai 7.775% $7•58
Other $0.00
FET $o.00 � TOTAL� $300.01
Supplies $0.00 � _ __ _---__�
_ _--------- -------�- ------- -----------__----- _----..__ ___
NEW T/RES carry manufacturers xarranty if any(ask associate for ti�e 6rand warranties).All new tire package.purchased from Tires Foi Less crome with our Lrfe6me Rotatwn.Lifefime Balance&hee Road Hazard
wanantyQimited to repair only).USED Tires rarty a standard 30 day warranty limited to defects onty(Road Hazard waoanty is rrot induded with the sale of Used Tires).Any warrarrties on New&Used Tires sold by
Tires For Less he�eby are tlrose of the Manulacturer.As beM�een Nie seNer&buyer,The product is to be sdd AS IS and the entire nsk as to the quallty and peAormance of r�ew&used Tires is with the 6uyw.
UNDER NO CIRCUMSTANCES SHALL TIRES FOR LESS BE RESPONSIBLE NOR UABLE FOR THE COST AND/OR IXPENSES OF DAMAGES.REPAIR.INJURY OR DEATH CAUSED BY ROAD HA2ARDS '
DEFECTS fA1LURE OR MALFUNCTION OF NEW&USED TIRES..Pads and Labor warranties lOQ%fw 90 days or 4000 miles,whichever comes first This warranty limited to the Mrork on thislorm onty.VehiGe
must be refurned to our shop at customer's expense,to horror warranty.t hereby authaize the repair work to Ge done along with the necessary materiaJS.You and your empbyees may operate vehiGe for
purposes of tesBng.inspection or delivery at my risk.An express Mechanic's tien is adarorlealged�n Nehide to secure the anaunt of repairs thereto.You will nof be held responsi�e forbss or damage to aehide
or artic�es left in vehiGe in case of fire,theR,accident or any other cause beyond you�control.Because of the extent o(the teardown and rnspection.the vehiGe may not perform as well as before.No refunds on
rnstalled Tires and a Wheels.Special Orders a discontinued items Al/retums are subject to 15%handli�ch�3rge.Any de,00sits are subject to IoAeit if canceUed.Due to high sensativity of all wheel drive and 4x4
vehiCles it is always recomended that you change a114 Hres with new 6res,if the customer decides to purchase used tires,Tires For Less will not be held iesponsible for any damage causea'to fhe Mansmission of
trensfei case.
BY SIGNIN�.1 UNDERSTAND THE WARRANTY FOR NEW&USED TIRES FROM TIRES FOR LESS
Print Name Signature Date
. 3
I JUST IN-TYME TOWING �
� . _
_ ..�� 266 Burgess �
St. Paui, MN 55117 °
Date � � ��f ]
ss�-�aa-aa�s ,� r� ;
Name ���1' �x��'�— s
Phone ;
F �
Address f�Y'r-2��' � ,�i;����'r,r't_J �City����-a' :
~�
Comments �
Acct. Mbr.# P.O.# �
. ; ,_
Pick Up Location <"���f���� P one �
f
Taken To%�. n:'� �'�-� r' � �' �r� ho��.
Time In Time Out Total Time #
Flat Bed � Wheel Lift ❑ Wenched ❑ Other ❑
�
�!Gomments:
RAT�ES ,6�t�M��'�:
��. � �
Hook Up Charge °� � � f��=� t� ��� '1�
F � 4
Miles Towed /'�'�_ Rate Per Mile � �
In Route Miles Rate Per Mile �
❑ CHECK# �
YR. MAK 0 CASH SALES TAX �� ;
�–
� ,��Y � ❑ CHARGE TOTAl. �� %
MODEL COLO EXP.oate
� � i 1 UNDERS{CsNED.DO HEREB'�'GERTIFY THAT 1 AM LEGALLY I
;'� : • r � f'�,,�;/�,.,�,,- RETQ AUTHOR{ZED AND EMTITLEDjTO FAKE POSSESSiON OF THE
,J ���� � /i.�� VEHICLE DESCRIBED ABOVE AND RLL PERSOlJAL
PROPERTY THEREIN IN ! PRESENT CONDl710N ATID
�iCENSE # AGREE NO FURTF�R Y�L BE MAQE AGAINST JUST-
IN-TYAAE TOVMIN(i�ST PAUL
�
; �i;' t � ,�i � NOT RESPON8l8lE FOR LQ88 OR DAMAGE TO VfHICLE
1 '. � 4 I
� � � t' � FET�NOT RESPONSBlE FOR LdSS OR DAMAGE TO CARS OR
`, ARTICLES LEFT IN CARS IN CASE OF FIRE.THEFT OR ANY g
V(N � � •O� CAUSE BEYONO R CONTROL. �
.{ r
t ' �
Signature ''-' �'� '