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MAY232013 CITY CLERK N�1,ICE QF CLAI�VI FURI1� to the City of Saint Paul, Minnesota �lfiirilc sutcr.Stertc�Srurrur=1h6.01 stcrte�s thcu ' ...e��c�����ers�un...wh�>c•luiin,+dsrrnu,4 ea flYi7Yt CIYdV 717lf)1ICf�)C7I!/�'...5'{lflll['[lllSN f0 J7C�1YNJ'N1J/N[I h�f{1N ,�!nrerrtin,��L��dv n/'th�»runirip�rCity wiihirt I Nll�Irru��1(1er I/tac rellek<�d lu.s�ur rrtjttrt°i.�•rli.x•nv<�rt�d rt nnlice�.�lrrlu�X lJte lintr,pinrr,rtnd ��irrum.rmnrc�s t/rerr�nJ;ancf tite�unn�en�nf rnin�en.uitinrr nr nther relief demcand�rd,' !'Icuse c{>�»picte this form in its enti�-ety by ctuurl�° h pin}�or printin�;�our��ns�rcr t��e:�ch yucstiun. If n�ure spacc i� nceded,�Itach acfdiliun�l shceis. 1'Icaze nole ll�at��►u will nnl!te cont�cied b� lelephi►pe!o cl.�rif� ��nxti►�rs,s�►pro�ide.�s much inliirmatinn as n�cessary to expiuin��our clain�,��nd the antuunt c►I'com�e�s�tion t�ein�rc�qucsted. 1'ou will recci�•e a ��riUcn ackno�cled�;crnen(once r��ur form is t•ecei�id. 'I'he process can t�kc u�s t�r tc�iti weeks e►r lon�;er ctrpendin;;on thc n�ture o1'yuur cl.�im. 'I'hi�1'urm mi�sl be si;;��ed,ancl l�oth pa�!es ri►�n��leted. It'sometttin};d[�cti nnl.��►ply,►�ritc`N1;1'. SL+'ND Ct�):YIPI.L'1'I:U FORR%I ANll �J1'HI;R UOCUNIk�N�I'S !'O: CI"I'Y CL(�:l�K, 15 �'�'ES7' KN:III./tlG(� BI.VU, 31(1 �'I'1'Y HAI�L, SAIN'1' PAU1,, R�1N SSlt12 Fii�St Name1�}.�V��VE Middie Initiai,�`�Last Name ��1�'-�,��� Comp:lllV��r Business Name 'S'Ttt�tc--�--�`TI,� 1�-t.���,,s' Arc Ycn� c►n lntiuranc:c C'c>rnp�ny'? Yc, No (f Yr�;,Cluirr� f4fumhcr? Street �ddres, _ ��J�� C�-�i(�.�,�� /��/s Cily �� YN�� Siale �lJ Zir Cc�d���U`-C—��/� Daytimc Pt3or�c(bSl)�-��C:cil Phonc( ) - f;v�ning"E'cicphonc(�c+`-?I )(o� -3�9 0 Date of.Accide��t/lnjurti°or I�ate [�iscc��•erecJ _ ��\lo,}��3 Time �� � am/ rn Plea�e �tale. in det.ail, �4�h��t c�cri.�rrcd{h,ypfienrd}, ,�nd �vhy yc�u are tiuhmittin�a claijt�. Fleaye inciicatr wh}'un c�,w yuu feel t}�e C'ity of Saint Paul or itti emplt�yees are ir�vol�ed ar�d/or respqntiihle fc�r youur e�an�ages._��1/�� �v�( o1J C_�-�� F��i�v� - -t'a v01 �1C� �"T--�--�°�,_�.-E--..��`�G._��'_� � ►�`�-.�...� `�, C..s��-f3�N �t}{� �LG�-E�' 1--1 . m i � C ' � o �-° �YL w�i2 � l dv'�' N°�" N5 c�F `� t�C> 1—L� oN� � �-i-11� ��r��� �� Tx--� �-��l t-�4�E S�.�.�c� i3�.�J ,�r c L�� (S�`-- �I�T�S�, � P casc chcck thc hox(r.$) that rrtc�st cic�sc;ly r4�rescnt t.hc�-c��c�n ti>r romp)ctin� this li�rm: ❑ Nly ��ehicl� wa*d<imar�d in i!)1'11C1t�ifll ❑ I�'I�J ��ehicl�+�vas d�.ima���d durin�:�(caw• 1�4(R4y vchicle was cl.arr�tt�e�l by�pe�thole r�r conditiun of t}t�street 0 R'1y vehicle was clarn.i�c;� hy a plow ❑ h�1y vchicic was wron�fully c��wcd uncllc�r tickctccl ❑ i wax injurccl an(:'ity prc�perty ❑ Qlher ty��e of properk}�clamage—ptease specify �❑ Other typc:c�f injurY—ple�<tse specif_y In �rdr.r to proccsti your c{aim 4•ou nced t�►includc cunics crf all apnlicablc documcnts Fc�r lhe claims ty�es li�;te.cl helc�w, plc>a�e he sure to include the docuntent�+ indicated��r it witl clelay the handtin�c�f your clai�n. Docum�nts b�'ILL�+10T be returnecl ancl t�c�me lhe pra}�rtV af the Cit}f. Yuu are eneouraged to kee��a c���y 1i>r y�iw's�ll'hcli�ru suhn�ittin�;yc�ua'cla[rn lixn�. � � Prrynerty damagc;claim� lU:� vehicle: twc�etitimatc:s li�r the rerain lo yc�ur vchicl� iC the damu�,c cxc�ccis SS(KI.pU: or the actual hi(ls and/or receipts for the repairs O 'I'owin�cl:iini1; l4gih}c copic:;c�f any tickct issucd and a co�ry c�f ihc impc>und lc�t rGCCipt O ()lhc►•��rc�rc:.r�.y da�l�u�c claims: �w�o ec��il1C l'.tiL111lit�Gti 1I �flt'LJitll)ii�C GXCCI'C�ti SS�M�,(X);c>r lhc 4tciu�tl hil), �ulcJ/ar rc:ceipts for the re��airs; detail�d list af damaged icem�; � O Injury clairns: rnedical hitis,receipts � 1'hcnographs arc: al4v<iys wcleomc tu drx umcnt�ind suprx�rc yuur clairn hut wil) nc�t hc�rc[urncd. Pu�c 1 of 2—Please comptMe and return both pa�es of C',taim Form �ailure to cam{�icte and return both pa��.s���ill result iu dclay in tlie handlln�;of your claim. Ail Ci.iims-please cumplete this sectli�n Were there wi[nesseti to the incident? Ycs No ��knc�wn lcircle.) 1'rc�vidc lhcir n�►mcti, addi-c,titic�und lcicphon�:nurnhcrti: ..... .�..._..�_ _........_..,�,�_.,_...�......,...„......_...�__M_____�._.._._..._. V4'crc thc i�olic�;c�r law ca�l�orcc_mcnt.cuilcd? Yeti Nc� lJ��knc.�wn (circic) If ycs, whal department or a�ene}''? Case#or re�ort# 1�'hcrc did thc acci�i�t�t or injury t��kc plac�'' 1'rovit34 strcct address,cro�;x slrcct,intcr�cclio». �iatt�c o��ps�rk c�r liicility, rlose�t laj3dmark.elc. I'Ic.asc k�c;;is detailed a, pos�iblc. lf necc�sary.altach a diagram. '['�� uJ�S� SI �1.�_v�- �1�l_:--�n.) �1�^;�..»:T�d�T�1: , � :.� ►�J�, A ��?�I�C.L�-q Sc��i�l o� T-��- � — Please indicate the.amc�unt you are see � ng in compensation or���hat y��u would (ike lhe City to do ta resolve this claim tc>vcaur 4ati�tactic�n. � �i��3� � � �J c 1�-�� �--�� �s:� � -t� �i�d t A,4 0 � -�'i �s �1�-+ 3�t e� �=f(�2-�r�-Y�, � �,,.,a��,.,.b ,�P��u.��t--E ,-�-I t�rt I,aw-��d c.�� ,f��sa 3�..e , �'ehicle C'laims please comUlete this section � � ❑ chr.ck hc�x if thi4�ection doe_s nc�t a ! � Your Vchicic: Ycar'��'�1 h7akc_�-��/.,.._ ; Mcx3cl � '-U --- a,i��:t���: I'l:itc E�liimhc:.r'�L__�.,�_�,..� �talc V�.i►J Col��t'_...�-`�_, ...._...� Re`ristered O�h►�er����F v►c- v� �-lA.�tL.�.v t_.T/ 5`cYL.k.`-C �-�--y�L Drirer c�f Vchicle '�11..1,C Arca l�.rrr�agcd SZ-� �-� 1%tlLoy� �tE Z:i_ ,T1� 1-��G,4r� City ti ehicle: Y�ar Make Model Lic�nse Platc Numhcr State C:t�lor 1)rivcr c�l'Vchicic(City I;m(�lnycc'ti Nam�:) _ --- - -- Arc<a L?atnagcd Injurr ('latmti plc�i�c cumple/c� thi`ti�ction �hcck hox it�this sccticm clvc�nut aPniti� ►�low ��crc. you i��ji�n:d'' �'Jhat part(s)ot your body w=cre injureci•' Have yi�u sou�ht medic:al treat�3ient"? Yes Nc� Ptanning to Seek Treatrnent(circte) Whcn cli�i you rccci��c treatm�;nt? ___________._(Proricic datc(s)) Namc c�l�hlcdical Nrc�vidcr(s):_. --- Address Tcicphonc Dicl y�ou miss�vork :+s a r�sult of your injury`? Ycti No VWhcn dicl you rniss w<3rk'� (pr��vidc datc(s)) N.in�e o}'your�,tnrloyar: Address Teleph��ie �.heck i�ere[f�ou are attaching more pages tu this cl�im form. Nu���ber of addittonal pages fjy Sl,���riit�,r lltis J'ornt,you ur'e st[tli7t�,r 11�ut all i�i/'or►rtcrliuit you I:ave provided it h•r�e a�rd cnr��ect to llie /iesl of your k1�o��Jledge. L'�isigned f�rn:s will not be Nrcfcessed. S�rh,�rirting a jalse claint c�uir rcFsttll ili J�i•usectttir�n. Uate t'�rm .�a�complrted 'a3! t3 1'rint thc \�n�e ol'llac Pcrsc►n Khcx Ci►mplct�d tliis H'orm: ��-'��/1�� ���t�t�-L Si�n�ture of Persou�Iaking th�Clain�: Re��ised Nebruary 2011 —z�� �/{--`1�-� I�.-�C�--�Yl- 1��. �v e }-�L� l.��-'3 �l L 1..�=�� � �(o:� �-/�i� �� �J--t � �t-�'► `' � �1 R-�'� ►-k*L`� (3�.'N 5 t�►�i v-�U 1 rh-� i T - I fJ�/o�C.� � '2�z-E..�P l „64.�._�a ,4't�✓�c(�-� CRR-X TIRE $ AUTO 861 UNIVERSITY RVENUE W. ST. PAUL. MN 55104-4702 651-228-9093 HOURS: MON-FRI 7:30 TO 6:00 SAT 8:00 TO 3:00 SUNDAY - CLOSED �**�**� I N V 0 I C E �****** I N U 0 I C E 12:20 PM INUOICE# 0726568 ESTIMATE# 1986 EMAIL: STRAY FERRL RESCUE GENE MRRRULT 04/22/13 937 CHRRLES MILEAGE: 40574 LIC# VXU582 ST. PAUL 07 CHEU AVEO MN UIN# iHGCG3169YR019148 55104 DRRRELL W. 651-644-3890 QTY ITEM# DESCRIPTION RMOUNT NET ---- ------------ ------------------------------------------ ------- ------- ir RIM STEEL WHEEL 159.93 159.93 2r T15480880000 1856014 GENERRL ALTIMX HP 81.99 163.98 2r MB MOUNT & BALANCE 15.95 31.90 2r US URLUE STEM I 2.00 4.00 2r TD TIRE DISPOSRL FEE 2.00 4.00 Zr TPP TIRE PROTECTION PLAN 9.95 19.90 ir LFRT LIFE. FREE TIRE ROTATION .00 NO/CHR TIRES SUBTOTAL: 383.71MECH# 405 ANRREW L. lr SF SHOP FEE 25.12 25.12 SHOP SUPPLIES SUBTOTRL: 25.12MECH# 405 RNDREW L. ir SUBLET USED HUBCRP 35.00 35.00 MISC SUBTOTRL: 35.00MECH# 405 RNDREW L. TRX IO # 42462 SUBT> 443.83 TOTRL TRX> .00 Paid by: DISCOV 443.83 -- .. T-PARTS: 392.03 T-LRBOR: 51.80 tHANK YOU FOR COMING TO CRR-X TIRE & RUTO PAY RMOUNT » 443.83 I hereby authorize the above work to be done along with the necessar ,� naterial and hereby grant you/or your employees permission to operate the car �r truck herein described on streets, highways or elsewhere for the purpose of testing and/or inspection. Rn express mechanic's lien is hereby acknowledged �n above car or truck to secure the amount of repairs thereto. Please see your warranty envelope for detailed warranty information. -or custom�r service call 1-800-504-7361 or email customerservice@carxauto.com S I 6 N E D:------------------------- ,. � �" � ' - � �. � .... . , '� � � � � � � ����.�r � �, � � � �� . K��� . � ''�'�:. ,.� . ., .aw. .�14V . A .r�i-` .. -._r . 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