Martin RECEIVED
� ' JUL 1'7 2013
N�3TI� QF ��.�A� ��RM te the �ity ��L��K.�ges4ta
Minnesota State Sltrtute 466.05 states thai ...every person...who clurms damages from any mr�nicipaliry...shall cause to 6e presented to the
governing body of the municipaliry within 180 days after the alteged loss or injicry is discavered a notice stating the time,place,and
circremstances thereof,and the amoimt of compensation or other relief demanded."
Piesse�a�t�s farm in its en�rety by cieariy typigg or priu#�g y�►ur ans�er io each c��esbion. If more space is
�:��s�eets. Please�te#�at yeu v��et�e�b�te�tfl€)ari�y answers,so�trn�ie as
��rh�n as�ece.sssty tv e�1�i�t ya�r�I�:`m,�ttl#�e s�t o€cs���be�g rec�esied Y�wiB receive�
writEc��o�vh�e�t a�y�c�r�is recexv�. �e�vt�s ca�t���g te�€w+eeks t��C►nge�'��g an the
sat�re e€y�-�. Tf�s���st be�d,��gages e�terl. �€s€��e�g dces�at�,�v�e`NiA'.
s�������.���.�������������.���� ��: ��� �����.,
15 i�EST I�I,L��BL�, ����I�'Y HAL�,��i�'PAUI.,M� 55If��
First Name �✓�y Middte Initial �-I.ast Name �••r--}''r1
Company or Business Atame
t�re You an Insurance Company? Yes No If Yes,Clapm Number?
Street Ar�dress Z Z o -"1`�' S-�. E�.+S�'
City ��5'�+�� State � � �ip Cade 5 � 3 3
l�a one -=1 Cell�'hone (�5 t 33 g'te3�` �
Y�,�_�.__�___�___ f�) Eve���o�e-f�--- -
r•e•n
I3ate gf AccideAt/�tjury or Date I3iscovered �"e�`� l 1='. �� � Ti�ne `� am/ptn
F�ease state,�detai�, what oecttrred{happe�ec�),a�c�why yoa are submitting a e�ai�.Please inc�ieate wky or haw yc►u
fee�the City of Saint Paul or its empi�ye�s are involved andfor responsible for yc>ur damages.
{t�c-s.-t sct �c.�� v�-tf -
Fiease�kee�t�ie baa(es)that n�ost cl�se�y represe�zt the�+eason for comp�etu�g i�ris f�rm:
�I My v��w�s damaged i�an accic�ent �1V�y ve�icle vvas d�naged during a taw
�ufy veh�c�e was datnaged by a potho�e ar conc�ition af�he screet C�My ve�c�e was c�naged by a g�ow
Cl 1V�y vehicte was wro�gfully towed audlor t�cketed ��w���on eiry�o�ny
II(�her t�e�Pr�xper�Y ciam�g�-�ale���i�--
�t�er type c�f��-giease s�ci€y
�ord���pr�ss yc�c��yflu�d#����f ati an��le da�c�ents.
�or�e c�aims types i�stEd be�sw,�as�b�e sur�to incl�de the tic�cument�i�cateci ar it wi1�delay the�andliab tsf
yt�ur ci�m. �m��s��:�fl�f'be returned and became t�e grop�ty af the City. Yc�u are�ncouraged tQ keep a
cogy for yvurseif befc�su�miiti����r claun form.
�Property dar�age�Ia�s tQ�vehicle:iwo estirnaEes for tiae repai�s to 3�c�r ve�c�e if the damage exce�s
$5{30.{30;or�e ac�bi�3s�dtor reeeipts for the.repairs
� 1'owing ciauus:legible Ec�pies of any ticket issued auc�a co}3y c�f t�e�m�aund Iot receipt
• �4thez prQP�ertY�g���a�s:iwo�e�est�mates if the c3am�g�exceeds$SQQ.41Q;nr t�e actual bills
a�/rn receipts�t�e�epairs;c�etailer��ist czf da�ageti i.tems
O lanjury claizn�s:�c�bi�s,reeeipts
Q Photogr�phs are atways we�cc�me to doe�nent and snpport yo�el�n b�t w�not be returned.
P�ge 1 of�-�Fle�.se cwrnplete am�retmra bot�t�g€s cif�Foan
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-piease comuletE this section
Were there witnesses to the incident? 'es No Unl�own ' (circle)
� Provide their names, addresses and t(elephone numbers: �"� �.�.t ►^ � « ��J�'"''� �,
l,J-t,1/� f-I�I.S�d IN-c G�..JJ✓� , ��In.. S�T✓/L,_�' �� /�` + � - {''-=r ....,,,..(r.�
Were the police or law enforcement called? Yes � Unknown (circle}
If yes,what ttepartment or agency? Case#or repc�rt#
VVhere did the accidenL or injury take place? Pravide sLreet adciress,cross street,intersection,name of park or facility,
closest la�dmatrk,etc. Please be as detai2ed as possible: If necessary,atkach a diagram. SQ^'�'S o-F 3 ('�-'ir< �a11�Pf
-��t w•�rt,. a.� Sc4--�s�-, a-� t,tn� • Le�+�-4.... ��r�►�s r��N�.b. vv� .�.�.a�, -i+
o� l a,,,.� a..-t -k•. l,�o�o�.y�t-�.. --- ll90►lt/ :� row2• 1�—
Piease indicate the a�unt you are seei€�na��co�pensatio�or what you w€�uki ltke the City to dc�to�esolve this clai�n
to your satisfaction. � ��N-� t�� -F� c��n -k'o �+� �1�- "'ht �►.u•.s �-tiP• �"�
rc...J -t'+�l i i..,r� '1'�c o�.l►ct...w.�-^I-
Ve�ie����ns ple�e cc►�plete t�is sectio� ❑check box if this sectian t�c�es not a�viv
Your�7ehicle: Yeaz��ti f1 Make�o y��ti. I Model L-�.�•�,
License Plate Number ��State /��' Color lr��
Registered Ow�r_�� N`'�+..
Driver Qf Vehicle '�'"`
Area I}amaged Z MMi, �� �.F�l o..�e ►(e�' l.�Gc l t�^ Q,..�- l -�'t ���
City Vehicle: Year Make Model �t:SN��
License Plate 1�I�mber State Color
Driver of Vehicie{City EmpIoyee's Name)
�t'ea Damaged
In�urv Clsims �p ca��ete f�section {a-e�k box if this section does not avniv
Hc�w were you inj�red?
What gart{s}of yaur bfldy were injured?
Have you sQUght mec�ical treatment? Yes Na Plaan%ng to Seek Treat�nt(circle)
Wtien did yau receive Lreaiment? (Provide date(s))
Name of Medical Frovider(s):
Address Telepho�e
Did yc��z miss w4r�as a result af yc�ur i�}ury? Yes No
Whe�did yc�u�ss wark? (Provic�e date{s})
Name of your�mployer.
Address Teleghone
L���ere if yau ar�a�ng mQre�tQ��f�rcn, l�u�ber�f�d�dugal Pages
�y sagrting this fvrna,yvu are stating that all i�fvr�ation yvu have prc�vidsrl is�and earrect to the hest
v�'yo�r�owledge. Unsigu�,��rms�vi.11 not be prr�cess�
Su�i�€reg a,false ctaim c�resutt in grvsecrrti�re. Da�Ee fg�w�c�mpieted- 2 cP Jw-t Z°� 3
I`�-^�-}'^
Print the P+taiue of the P�rs�whc�Cvmpieted f,h�s Farm: �'�`�
Signature c�f Fersa��l!Iaki�the Ci�m'
Revised February 2411
On Apri119�,after a spring blizzard that left the city buried in heavy wet snow, I
was driving north on Lexington Ave.
Just north of the Edgecumbe/Jefferson intersection I encountered three really big,
deep potholes in rapid succession.There was nowhere to go,as swerving to the left
would have put me into the oncoming traff'ic lane.A big loader of some sort was
parked in the right lane of Lexington Ave.so I couldn't use that lane to avoid the
potholes.
I saw one of my hubcaps fly off.The car behind me waved me down to tell me that
two hubcaps had flown off after I encountered the potholes. I turned around at St.
Clair to turn around and search for my hubcaps. In the few minutes it took me to
turn areund and park my car,two more cars had lost their hubcaps and their drivers
were looking for their hubcaps,too. I oply found one and had to purchase a used
hubcap to replace the one I couldn't fi�d. I did call the city within a half an hour after
the incident to report the pothole and found out that they had gotten several calls
and that the pothole had been reported the day before (April 18��.
I took my car into the repair shop the following Tuesday,as my back brake light no
longer worked and to check my tires. By the time I was done, I had to fix or replace
the following:
• Brake light wire
• One hubcap
• Alignment
• Wheel rim
• New tire
I'm submitting copies of the bills incurred,minus a second tire that I bought b/c the
repair shop told me it made more sense to replace two tires so they'd wear evenly.
The total reimbursement I am requesting is $368.94.
Please call me if you have any questions.My number is 651-338-6362.
Thank you,
Amy Martin
U CODE RESP� hi
T Q T A L .t-----,• �4 Ci.�!k7
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M �h � ( ���"�° �" Invoice #: 154895
I i1GREE il] FaV �hilUE tUiRL �hlGUfli � �! 5611 Kimball Court
fjyyiiuii7��j ��� �aF�� t.�uF.� a:��ECi��sis � Chino,CA 91710 � Date : 4/24/13
;P1E;t�HN�I� �l,htti+.E�i� Ih ��REGii U�'��t!rki � � (909)597-2600
�soo�s26 ssso Account #: 6513386362
_�,,����,.� . �., _.,._., _, _.. _.- -. .__s
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-���'��i�js�i�tEF� Gz�P'�*�?k
SHIP TO:
i AMY MARTIN
Lzu I'i'H STREET EAST.
220 7TH STREET EAST.
HASTINGS MN 55033 �
inkswiggler@yahoo.com ! HASTINGS MN 55033
Sold bv Contact Pavment � Shippin¢ ETA PO Number
Chris Credit Card UPS 45 Business Days
Qty � -�. Parrt No. -_ ' Description Price Amount
1 61088 1998 TOYOTA COROLLA $40.00 $40.00
ALL SILVER 14"HUBCAP
Sub-Total $40.00
Tax $0.00
IIIIII
I
I
I IIII�I
III .00
I
II 40
* , 5 4 8 9 s * Invoice Total $
30-Day Return Policy-All Refunds/Exchanges must be done within 30 days upon receiving the order. **All Refunds/
Exchanges are only done for unused and undamaged items accompanied by a copy of the invoice.Unfortunately,we are
unable to honor a refund for any returned item that has been damaged during the return shipping.**Cancellations can only be
done on the same day the order is placed and before the order has shipped. **All returns are subject to a 10%restocking fee
(no less than$10.00). **The only way we can guarantee a correct center cap,is if customer provides all necessary part
numbers. **We cannot guarantee installation of hubcaps,nor hubcaps that have been broken/damaged by installation nor after
they have been on a vehicle.**All exchange/return shipping expenses are to be paid by the customer.
* WORKORDER * #108756
HASTINGS TIRES PLUS
✓
PH. 651-480-8817
Sold To:
ACCOUNT#: 136560
AMY MARTIN
1
HASTINGS, MN 55033 DATE : 04/23/13
Ph: 6513386362 WORKORDER #: 108756
Billed By: BRAD
1998 TOY CAM Salesman : TROY I. S#:1 Rt:
Mileaqe:222219.0 Tx:Y ER#: Ct:R COD: IWS:
VIN#: ICID#: Pazking Space#:
Unit Extended
Quantity Product # Size/Description/Mfr# ! TC MC DP BIN# Price F,E.T. Amount
1.0 PTMISC P 14 INGH RIM 1 I 117.00 117.00
1.0 LBMD DISMOUNT / REMOUNT TIRE N
1.0 LBTB ONE TIME BALANCE N 9 9g 9 99
1.0 VALVE VALVE STEM 1 G 2.99 2.99
1.0 SCRAP DISPOSAL FEE W 2.19 2.79
2.0 BJ1131 195/70R14 BCT 5600 AS 1 60.00 120.00
2.0 LBMD DISMOUNT / REMQUNT TIRE N
2.0 LBTB ONE TIME BALANCE N 9,99 19.98
2.0 VALVE VALVE STEM 1 G 2.99 5.98
2.0 SCRAP DISPOSAL FEE W 2.79 5.58
1.0 LBALCK REC, ALIGNMENT CHECK p
� FREE LIFETIME RQTATION Z
� PLEASE I�EP YOUR RECEIPT +
� IT WILL BE REQUIRED POR �
} FUTURE VARIFICATION �
1.0 LB4AL 4 W!�EI, ALIG 1 P 80.00 80.00
1.0 SS99-1 SHOP SUPPLIES Q 7.10 7.10
Merchandise Services 6 Other F.E.T. Subtotal Sales Tax Total
245,97 125.44 0.00 371.41 17.53 388.94
Comments: Terms: PO# DUE DATE AMT. DUE Misc. Adj. . . . . . . . $ 0.00
Cash or Check #: $ 0.�0
Ciedit Card. . . . . $ 0.00
Balance. . . . . C . . . $ 38B.94
Received By: Page 1 0£ 1
Started: 04/23/13 12:15 PM Promised: _ Completed: _
I