Burkhardt, LauraNOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesato State Stotute 466.A5 sfites that "...every person...who claims domages from any municipolity...sholl cause to be presented to the governing body of the
municipstity within 180 days ofter the alteged loss or injury is discovered a notice stating the time, place, ond circumstonces thereof, dnd the omount of compensotion
or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answers to each question. lf you have additional documentation you may add those
documents to your submission. You witt not be contacted by telephone unless clarification is needed. The claim process for investigations can tak€ upwards of
four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission is to the Saint Paul Citv Clerk's Offlrce. You may email, fax
(651-255-8574) or mail the form. Mailing address is "Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102"
lndividuals: First Name Laura Last Name Burkhardt
Please lndicate Your Pronouns: She/ Her/Hers X He/Him/His I_ They/ Them/Theirs I
Company or Business Name
ls this claim being made by an lnsurance Company? NO lf yes, what is your Claim/File Number?:
!s this claim being made by an Attorney? NO lf yes, what is your File Number?
lf yes, then provide your lnsured's/ Client's Name
Street Address:L724 37th Ave. NE
City: tVlinneapolis State Minnesota Zip Code 55421
Dayti me/Wo rk Phone _612-7 67 -486 2_ Cel I P h on e 952-215 - 4!83 -
Date of lncident or Date Discovered (Must complele\ U77/2A23Time approximately 5r15
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. While driving eastbound on St. Claire Ave. I
hit a large, difficult to avoid pothole resulting in my passenger side front tire popping and my exterior tie rods breaking on both sides
of the vehicle. I had my car towed a tire shop the following day because no tow trucks were able on 1.117 12023. An UD|2O23, after
the tire was replaced, I took my car for an alignment. lt was discovered both exterior tie rods had also broken and needed to be
repiaced.T|erodreplacementwascompletedon1.fia/2023-
Please state why or how you feel the City of Saint Paui is responsibJe for your Damages? Pot hole was large, difficult avoid and
caused damage to the vehiele including a popped tire and broken tie rods. The damage also required contacting a tow truck.
Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of
the City of Saint Paul and shall not be returned.
iI Automobile damage from a motor vehicle accident; please provide two estimates for repairs or actual bill that has been paid.
E Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid.
f Automobile was towed and may or rnay not have sustained darnage: please provide copy of towing ticket (if available), receipt
from lmpound Lot, and two estimates for repairs or actual bill that has been paid.
tr Snow Emergency: please provide copy of towing ticket (if available), receipt from lmpound Lot, and t\ /o estimates for repairs or
actual bill that has been paid.
f1 Property damage: please provide two estimates for repairs or actual bilt that has been paid.
[] You were injured during a motor vehicle accident: please provide police report number, details about injury.
I You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury.
This section must be cqmpleted for all claims.
lsthereapolicereportforthisincident? NOlfyes,pleaseprovidethepolicereportcasenumber
Revised Decembet 2021
lf yes, what law enforcement agency responded?
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
East bound on St. Claire Ave between Pleasant Ave and Osceola Ave. s. Occurred while driving downhill shortly after Pleasant Ave
Notice of Claim Form, page two, Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your satisfaction? Towing fee and cost of tire replacement and tie rsd
replacement (including labor) be paid in full.
Were there witnesses to this incident? Please provide names and contact phone numbers. Michael Kluball, T15-207-
8187
For propertv damage claims, including vehicle accidents.
Your vehicle's information: Year 2013-- lVlake Hyundai Model Elantra- Color Red
LicensePlate#9PS302-Statevehicleisregisteredin[Vlinnesota
Registered owner of vehicle Michael Kluball and Laura Burkhardt
Area(s) damaged front, passenger side tire and exterior tie rods
IfaCityvehiclewasinvolved:LicenseP|ate#Color
Was there City insignia on the vehicle? Yes No Driver's Name
Other property damaged :
fo: iniurv claims ot
What part of your body was injured? N/A
Did you go to the emergency room or urgent care? NO Where?
Was medical treatment received? NO Where?
First day of medical treatment?Are Vou still receiving medicai treatment? NO
Didyoumissanyworkasresultofthisincident? NO Employer(s) L.iirkri:-tiipherstctlifiiit t€::r:.
How much time have you missed from work?
lf you are submitting other documents, please state what you are attaching and how many pages. 3 pages including the towing
receipt, tire replacement receipt and invoice for tie rod repiacement.
By signing this form, yau dgree thot oll intormotion provided is true and corred to the best of your knowledge.
Please NOTE that submitting a false ar misleading claim can and will result in prosecution under Minnesoto Statutes.
Name of Person completing form k-,-.rix B.',-El.r-r-JI
Signature of Person subrnitting this form
Relationship of person signing to Party making the claim
Date dacument is being signed 7
t<"\ t
Revised December 2021
A7123,6:47 PM University of Minnesota Twin Cities Mail - Receipt from Waamo Auto Repair & Auto Body Shop
.Tf,Laum Burkhardt <burk0362@umn.edu>
Receipt from Waamo Auto Repair & Auto Body Shop
WaamoAuto Repair & Auto Body Shop via Square <receipts@messaging.squareup.com> Wed, Jan 18,
Reply-To: Waamo Auto Repair & Auto Body Shop via Square
<CAESQhlAGjRyX2l memhhNXpza3zoeGlxM3dvznd4azMybmS2cmdSc3NvbGZtZSVzbGllanZmcXJzMmxllghkaWFsb2dlZSlglFYPo4EI06BLgtvRxWSbauzeyc4O0ny/omLZDMgEkY=@reply
To: burk0362@umn.edu
Square automaticaily sends receipls to the email address you used a1 any Square seller. Learn more
Waamo Auto Repair & Auto Body Shop
Let Waamo Auto Repalr & Auto Body
Shop know how your experlefce was
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Waamo Auto Repair & Aulo Body Shop
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Jan 18 2023 at '11:29 AM
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Auth code: 0'12932
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1455 tr4arket Sireet, Suite 500
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INVOICE
STINSON AUTOMOTIVE, INC.
33OO STINSON BLVD.
MINNEAPOLIS, MN. 55418
Phone: (612)788-9229 Fax: (61 2)788-5827
Your Auto Service Specialists
INVOICE
72705
EPA MND022942536
1027 35804
Printed Dale: 0113012023 Work Completed: 01/30/2023
KLUBALL, MICHAEL and Laura Burkhardt
1724 37lh Ave NE
IVIINNEAPOLIS, MN 55421
Cellular (715)207-8187 - Spouse CEL (952)215-4183
2013 Hyundai- Elantra Limited - 1,81, ln-Line4 (110C1) VIN(E)
Lic # : 9PS302 Odometer ln : 149379
VIN# : KMHDH4AE9 DU515469
Part Desc on I Number
Tie Rod End-Front Left Outer
56820-82-000
Tie Rod End-Front Right Outer
56820-82-050
Shop Supplies
STINSON AUT(]fiO IIVI3360 STlNSON BOULEVARD
IlINNEAPOL]S. I1N, 55418
612-?88 922s
Sale
1.00 60.12 60j2
Sale Ext Labor Description Ext
'1.00 62.02 62.02
Hit a pothole and blew out front passenger tire, seems 240.00
to drive ok but would like and alignment.
- Test drive vehicle. The steering wheel is not straight and it feels
like something is bent or loose.
- Check specifications on alignment machine. Found both front tie
rods are loose. Necessary to replace the outer tie rods before an
alignment can be done.
- Remove and replace both outer tie rods.
- Test drive after alignment.
Four wheel alignment and system inspection. 120.00
Complete vehicle inspection report. lnspect steering and
suspension system components. Check toe, camber and caster
settings. Necessary to adjust front toe.***WHEEL LUG NUTS NEED TO BE RE TORQUED TO
SPECIFICATIONS. THIS IS A FREE SERVICE WHICH WILL BE
PERFORIUED WHILE YOU WAIT AND IN LESS THAN 15
IVINUTES. NO NEED FOR AN APPOINTIVIENT FOR THIS
SERVICE. PLEASE RETURN WITH THIS VEHICLE WITHIN 50.
1OO MILES FOR THIS SERVICE.***
Hazardous Materials 12.60
4.27
I Recommendations ]
(812312021) Tire pressure warning light will be on.
(8lnl2A21) Recommend tire rotation every 6-8,000 miles.
***There is no spare tire with the vehicle.***
CurrentEstimate 508.81
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TotaI: $
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Appr Code: 844ji0
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!Customer Copy
THANI{ YOU!
I Pavments. I
Labor:
Parts:
360.00
126.41
HazMat:'12.60
SubTotal:
Tax:
Total:
Bal Due:
499.01
9.80
508.81
$508.81
dhansen@s ti n s o n a u to m oti ve. com
Vehicle Received : 1 130 I 2023 Customer Number : 10616
on parts and labor is 1 year or 12,000 miles,comes must our shop & cannot exceed the cost of the original repair. Some
service charge of 1.5% per month (min. 50 cents) will be charged on all invoices unpaid after 30 days. Thank You. Stinson Automotive greatly appreciates your businessll
Signature Dalo
Emai I Add ress: d h a n sen @sti n so n a uto m oti ve.com
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