Fowler �iUlv/Lb/'lUl:�/���;11 lU, U6 A11�1 Ftiy 1��, RECEIVED p. 002
. JUL 312013
l�T�'�'�C� O�' CJLAYI� �E`OlRIVi to the Czty of Sa���a��t,�nesota
Mlnnesora Stafe Statute 466.05 states that "...every person...wlio claims da�nages from any municipaliry,.,sliall'cause to be presented ro the
governing body of t{�e municipality wrthin I80 days af3er the alleged loss or injury is discovered a notice st�ting the time,place,arul
circumsfances the>eof,and tlie amount of eompensazron or othEr relief demanded_"
1'lease complete this form xn its entirety by clear�sr typing or printing your ansr�ver to esch question. If moxe spsce is
needed, attach addxtional sheets. Please note that��ou will not be contacted by te�ephone to clsrify answers,so pro�ride as
m�ch informatzoz�as necessary to e�piatn your claim,and the amount of compensation being requested. �S�'ou will receiWe a
dvritten ac�;.novaledgement once your form is recelved. The pr.ocess can take up to ten weeks or louger dependtng on the
nature of'your clsim. This forzza must be signed,and both pages completed. Yf somethiag does not appl�,write`N/A'.
S�l�D C011'.��'LE�'ED F01211�I .A1�D OTHE�b�CUMENTS TO: CYT'Y CLERK,
15 �ST T�ELLOGG 5��, 310 CITY T�A�,�,, SATNT PAUL, MN" 55�.02
�,irst Na•me_ �S�\� l�%tiddle 7nitial ��. �.ast Name. �GU�►\-E'�C
Cpmpany or$usiness Nan1e �Q N�
Are�''ou an Tnsurance Coz�apany? Y'"es/ To If'Yes, Claim Number? N I �
Stz-eeiAddress Ib�b S`�-\\\ �r.IOQ� �'t �JE�r�v�
Cit�� S G i`n�-- �QV\ Staxe �`C�C1 Z�p Code ��� C�
Daytizne Phone '1iv W1�-tiqqG Cell Phone (-1�)�O�C ��°�ening Telephozze ��5�����'
Date of AccidentJ Tnjury or l�ate Discovered��,��� Zi� 2-v�^'`� Time ��c�
�;�.1� am/�
�'lease state, in detail, +xrhaC occurred(happened),and wh�.�ou are submitting a claim. please indicat�r�rhy or how you
feel the City of Saint Paul or its employees are invol�ed andJor responsxble for your dama�cs.� � -�����,
t q�-} cx� c-�S�. �.t��� h�c��r.c-� h,cx-c.e wti�h \ S'K�`� y mCZ�hUicJ
c� �.:� 1c-r�,�-��c�- � h�i� ��CYi�" ��i�'�S?�r ���� -�e 'tC���C-rti� �`'� ��,c
�'c-r.�-��N� �c� �c�1 ei�(yc C't �l�-��'�='t c�at��.(�i�-t h� t���lF' � -re'� �`�'c'�� R1�,.�E
��L� ��'�cP<�_`�'�\1�-f CY'---tY�iC r-1cti� �c�-��'c'�a r'.c='�-i���� `K'i� ���aca E' �1
r-r �;21�'r i-,r 1 mr`rf.'C\►C���1 r�c1C��� :�c'� ��C�C S�'C'�� ���'c'<!i� C-����'t �'��l\ �\ '3c'�
�,� cE'�z-��-_���Q-°C oc a�\-Fi�� cJcr..� "��ri �c_�C?��� 'tC cr�� c'c�( 1�.�rc,.: �.
S�t-�c c� .`�i�`�
GM0.X�-! "F�c>"t �..�CL`�1i�!-�:�2 `�v� �a�c'�.-�--�h� �C;�e �rJ.�� Cc�:'�\ i rC� l-�S't�cc�C1 hc2�lF O�i�.
Please check the box(es)that most c]osely represent the reason for completing this form:
❑ IvLy vehicle`vas damaged iz�azz aeeident ❑ My vehicle wa.s damaged durin,Q a tovcr
f�'fVly vehicle w�s dar�iaged by a pothole or condition of the street ❑ N1y vehicle�vas darn3ged b�a�Io�
L7 �VLy vehicle was wrongful�y�owed and/or ticl�.eted ❑ I was injured on City property
C�3�Oth�r type of property damage-please specify���� c•�. �rSk�C� e=� �� Y�m
C� Other type of injury-please speei.Fy 'n��`�' cz-x�u.�� �w-t-��e c��e.-� cr��e,c� h�-�, ,
A ► �:�-t r �n c1�. `�c: �r-�� ot 1-���.�
Tn order to pzocess �our claim you need to inclnde copies of alI appXicab�e documents
For the cl�.ims types listed below,please Ue sure�to in.clude the documents indicated or it will delay the handling of
your claim. bocumen�s��NOT be retunied and become the property of�he City. You are encouraged to keep a
copy for yourself be�ore submitting your claim form.
Q properry damage claims to a�hicle: tayo c�imates for the repairs t'o your�vehicle if the damage exceeds
�500.00; oz the actual bills andlor receipts for the repairs
O Tow-in�claims: leb-ble copies of az��tieket issued and a copy'o�the impound lot receipt
O Other property dam�.ge claazz�s: t�vo repair estimates i�the damabe exceeds $500.00; or the actual bills
and/or receipts for thc rcpairs; detailed list o�da�z�aged itenis
O Tnjury claims: naedical bills,receipts
O 1'hoto�rraphs are al�vays welcome to d�cument and suppor�your claim but will no�be returne�
Psge 1 of 2-1'3ease com�lete ahd retulxA both pages of C72ITt1�'OI'ITl
JUN/26/2013/��ED 10: 06 AM FAX PJo, P. 003
Failure to complete and return botln�ages wvi�I result in delay in the haz�dling of Srour claim.
All Claims- lease com lete this sect�o
Were th�,re witriesses to the incident? Yes No Unlrnown (circle)
pro�ride their names, addxesses and te�ephone nu.rc�bers:"��r`c�� `c'ti�� -�-� ,v.�i� l�,\Z b�1v�S�� w
1 K�Gb �\��t� ��' ���c.-� - 'S\O�v
Were the police or law enforcement called? Yes No � Yl'z�laio�xm (cixcle)
If yes,what deparnnent or agency? Case#orxeport#
VJhere did the accident or injwry take place? Provide street address, cross street, intersection,narne of park or facility,
closest landmarl�, etc_ Please be as detailed as possible, Yf necessary, attach a diagram. ��� �C�Q�{'�
4Ce,���e ���r����c���ieti� �t-c� ���m�r�c,c,c� d��e-�i�i ��-f-t ea� c�
s�r�� proc�`.� cc'•�c��»�} LLC ��-1�5 �c as�'c�,r� S� t�.a�r SS��10
Please indicate the amount you are see�dng i.z�.compensadon or what you would like the City to do to resolve this claim
to your satisfaction. ���'��` l S ��t�'�"�c��E' G-4 :��s-��t n�-�"�S � C �c�CCT�' '�G
r C�C�1�C r`<`L-� c C�- bc��-t G h-c�� �� ��S t�t c�� 'c`c� c�icr�c�P C�C�C��CE' # Q''y�`�
Vehicle CXaims-- lease conn lete this sectioz� ❑ check box if this sectioxz does not a 1
Your Vehicle: �1'ear�C', Make C'c��J� Ivlodel �mC� ► �\�v
License Plate Number �►� . �_ State�Color r��> >�
Registercd O'cz�za,er, -�F��\� �--�c���-�
J�river of Vehicle �\e • �� �
:�-ea Danaaged ��( � Y�ee� � � � �-1 i
City'Vehicle; Year Make J.VIo el
L�cense Plate Numbex State Color
Dri'ver of Vehicle(City Employee's Name) !
Area Damaged
In'u Claims- l�ase com lete this sect�o�► �ficck box if this secrion does not a l
How were you injuzed7
What part(s) of�otu body were injured?
Have you sought medical treatment? �Yes No Paanning to 5eek Treatrrxent(circle)
When did you rccei�ve treaunent? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you znass vcrork as a result of�our injwry? Yes No
�k,,en did�ou miss work? (provide date(s))
Name o�'your Employer:
Address Telephone
P�Check here if you axe attach�more pages to this claim�foz-zn. Number of additio�,al pages 1
c�,�Sc�r�c�z+�a crat� -t ��►-�c-°t-cs ..
$y signing th�s form,you are stati�g that a1C infor-�rtactior�you have,provided is true and correct tv the best
of you�krzvwl'edg� UnsYg�ted forms will nat be processed
Sub�nitting a false clartn can resurt in prose�cutio,n. Date forrzx�vvas completed ��'(1� �-� ��L�� -
Prini the Name of t�e Pex'son who Completed this Form: '�`�h�� 7 �����
Signature of�exson Mal�ing the Claim: �v"`-'� �� �� � �-�
Revisod February 2017
� �re
TIRES�8ERVICE�BRAKES•BATTERIES
MN NATL TIRE & BAT # 875 * * E S T I M A T E * * Page 1
2185 FORD PKWY Order Number - 43072240-ET
ST PAUL MN 55116-1816 Date/Time In. . . . . . . . 06/27/13 15 : 02 : 38
(651) 690-5007 Est .Time Completion. 06/27/13 16 : 02 : 00
OIL LEVEL: Checked Empl#
Verified Empl#
Lug Torque : Actual 2010 CHEVROLET Malibu
Checked Empl#
100 Verified Empl# Tag: JBE311 St : MN Mileage: 1
Tire Infl F-30 R-30 TPMS Y N Engine: Vin: lAlAlAlAlAlAlAlAl
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Customer: 34229458 PO# : Ship To:
FOWLER, ASHLEY
1606 STILLWATER AVE
ST PAUL NIl�T 55106
Opening Salesperson 12965207 Home# 763-670-1990 Work#
Email :
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Item Number Item Description Qty Price Each Extended
-------------------------------------------------------------------------------
GY29121557VNEW Gdyr Assurance Fuel Max 1 147 . 99 147 . 99
738735571 215/55R17 94V, 738735571
Tire Disposal Charge Tire Disposal Charge 3 . 00 3 . 00
PTT SERVICE CENTRAL NC INSTALL TP 1
TPMSKIT TPMS REPAIR KIT EACH-12993 1
NCb WHEEL BALANCE NO CHARGE 1
KMTSL MOUNT AND INSTALL 1
LTRF LIFETIME TIRE ROTATE SVC 1
SCRoadHazard ROAD HAZARD WARRANTY 1 22 . 19 22 . 19
LBu LIFETIME BALANCE 1 9 . 99 9 . 99
XPWH XPWH 17X6 . 5 FACTORY ALU RIM 1 179 . 99 179 . 99
New
TORQUE CUSTOM WHEELS MUST BE 1
TORQUED AFTER 1ST 50 MILES
WHEELMSG ALL WHEEL SALES ARE FINAL 1
NO RETURNS AFTER MOUNTING
WA WHEEL ALIGNMENT 1 89 . 99 89 . 99
5 Menths / 6�00 Mile
IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK
TO OUR STORE MANAGER, WILLIAM PUNCHES
AT (651) 690-5007
PLEASE READ CAREFULLY, CHECK ONE OF THE STATEMENTS
BELOW AND SIGN: Total Charges . . 453 . 15
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