Mills, Aaron (2)NOTICE OF CLAIM FORMtaeeGBof saint Mnnesota
Minnesoto stote Stdtute 466'05 stotes that ",3very person"'who cldims
munlcipalw within 180 doys aiter the olleged loss or iniury ls discovered
ot
presented to the governing body ol the
qnd the-amount of cq4Pensation
Please complete this form in its entifety
documents to your submission. You will not
weeks. This form must be signed, dated with all appllcable
{citycle*@ci.stpaul.mn.us},fax (651-26&8574) or mail
CjaimanL FirrtNams.f-
hXctearlv tYPins
be coritacted by
or printin gydur answtrs {o ealh
telephone unless clarification is
documentation, you maY add those
investigations can take upwards of four (4)
West
Narne:rur, tt /
Please lndicate Your Pronouns: D She/Her/H e$, d*e/HimlHis, I fhy/ Them/Theirs
&.
Company or fiusiness Namel
rs this claim being made by an lnsurance compqny? YES /@ lf yes, what is your claim/File Number?
ls this claim being made by an Attorney? YES /@ lf yes, what is your File Number?
Ii I
lf yes, provide Your lnsured's/ Client's Sme:
Street Address:k{)A-o-^d
City , 5t- f*--{State:hstt Zip Code:55rta
Daytime^vork Phone: 6gl -,\$,b'a Tno- . . . €ellPhoner )lL .35 6-ti
Date of lncident or Date Discovered {Must Complete):qt \LI L}Time:
{1 i
Y'"* P &n'
Please state, in detail, what happened that prompted you to file a Notice of claim w1 {f-,,ftr *la- &{o *4/ {i re
aun-
Please state why or how you feelthe'{&r#.ffiPaul 3 ^s't {*{e *,^r .t[*1""t"
fl*"1 hola
Please check the reason that most closely describes'.tk'reason for your submitting a claim. Please note thedocuments that will
need to be provided with your completed form Photographs will be accepted. Alldocuments submitted become the proPertY of
the City ofSaint Paul and shall not be returned.
&
EAutomobiledamagefrom]*motorvehieleraeeidg*tfptEffi'p#wid€two€5timatesto,idiq
t ". - ,-- ^-!-.^l L:ll tL^*h^+d Automobile damage from a street defect or p'otholeilBase provide two estimates for repairs or actual biII thdf hasfitErrpaid., ""
i;r.
fl Automobile was towed and may or may not have sustained damage: pleaseSrovCe Eqsy of towing ticket {if available}, receipt i.
from lmpound Lot, and two estimates for rrytre€rffiialbffi:rt}E#r@eenpaid' . | -.:
E Snow Emergency: please provide copy of towing ticket (if.arailable), receipt from lmpound Lot, and two estimsrlE'for repairs or
actual bill that has been Paid' .
E Property damage: please provide $Jvos8eirfr*es#rwia*cr:'aEtEal.biuthat.has beer@* l :;,. - r}i1l
[f you were injured during a motor vehicle accident: please provide police report number, details about injury.
E you were injured in the City of Saint Paul: please provide police report nurd*., wl$eChs, and details about injury'
ii- ''ll. '; ':'i '
continue to pagp 2 of Notice of claim Form. Failure to complete and return both pages will resuh in deliys'
(-
i,^r- t-t
l
Revised Morch 202i
by email
g
This section must be completed for all claims.
ls there a police report for this incident? yES /@
lf yes, please provide the police report -ase number:
lf yes, what law enforcement agency responded?
place? Please provide a street address, intersection or name of city park or facility:{ €ri *r
What would you like to see happen to resolve this claim to your satisfaction?
Ld {-^f i-lr-<-
Were there witnesses to this incident? Please provide names and contact phone numbers:{vo
For propertv damage claims, including vehicle accidents.
Your vehicle's information; Year: Lo l"l Make: fur!Model:[' *r ' '--Color:{i r*>
License Plate #:L.r--J State vehicle is registered in:tvt-tV
Registered owner of vehicle:&*trn w,Itt Driver:&*r,"' 4r,t rr
Area(s) damaged aILf f., fi,*r*;i {'L
lfaCityvehiclewasinvolved,LicensePlate#:Color:
Was there City insignia on the vehicle? yES I NO Driver,s Name:
Other property damaged:
For iniurv claims of anv tvpe.
What part of your body was injured?
Did you go to the emergency room or urgent care? yES / t,tO Where?
Was medicaltreatment received? yES / NO Where?
First day of medical treatment?Are you still receiving medical treatment? yES / NO
Did you miss any work as result of this incident? yES I NO
Employer(s):
How much time have you missed from work?
lf you are submitting other documents, please state what you ar€ attaching and how many pages;I t.t Qqls-ca# lL<c*{e'{
By signing this form, you agree that all information provided is true and correct to the best of your knowledge.
Please NOTE that submitting a false or misleading claim can and wilt result In prosecutlon under Minnesota Statutes.
Name of Person completing form:/*c**r*i,."irtJ
Signature of Person submitting this formt
Relationship of person signing to party making the claim:
Date document is being signed:4 /iq ft>
5elf
Revised Morch 202i
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PARKWAY AUTOCARE
1581 FORD PARKWAY
sT PAUL, MN 55116
651-698-3208
4ltZl2123 2:55:37 PM CDT Repair Order #L33337 Page:1
MILLS, AARON
1640 BAYARD AVE.
SAINT PAUL, MN 55116
Vehicle = 2OL4 Ford Fusion 2.O L122 CID L4 DOHCVIN :3FA6P0K95ER2L270L
Fleet #/Driver:Created i 41121202310:25:39 AM CDTCompleted :411212023 2:55:31 pM
Phone: 551-355-9402
Service Writer : BJM
Taglstate : MYN225/MN
Odometer In
Odometer Out
90300
90300
Pafts
code Description
Advanta HPZ-01
Note: 235/40R19 XL 9BY - Not Run-flat, Peformance All Season
NRE DISPOSAL
Condition Unit Price
$131.ss
$6.00
Price
$131.ss
$6.00
Tires
Shop Supplies
Hazardous Material Charges
Charges
Sales Tax
$131.ss
$3.9s
$3.s0
$6.00
$11.42Sales Tax @ 7.875o/o
Repair Total
PAYMENT
BALANCE DUE
$1s6.42
$0.o0
$1s6.42
Technician Code Certification #
CM
Approvals
Date & Time Total Amount Authorized By Method Employee
STORAGE FEE. 12 l\,lonth or 12,000 Mile Wananty On Repairs.
Customer Signature _