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Daniels, ShannaonNO11CEOFCLAIMFORMtotheCityofSaintPaul,Minnesota,nnesotoStateStatute466.05statesthat“everyperson...whoclaimsdamagesfromanymunicipality...shallcausetobepresentedtothegoverningbodyofthenunicipolitywithin180doysafterthealleged/assorinjuryisdiscoveredanoticestatingthetime,place,andcircumstancesthereof,andtheamountofcompensationorotherreliefdemanded.”Pleasecompletethisforminit5entiretybydearlytypingorprint/ngyouranswerstoeachquestion.lfyouhaveadditionaldocumentation,youmayaddthosedocumentstoyoursubmission.Youwillnotbecontactedbytelephoneunlessclarificationisneeded.Theclaimprocessforinvestigationsntakeupwardsoffour(4)weeks.Thisformmustbesigned,datedwithallapplicablesectionscompleted.SubmissionthiscompletedformtotheSsrtPaulCityCierk’sOFicebyemail(citwlerk@ci.stpaul.mn.us),fax(651-266-8574)ormailaddressedto“SaintPaulCityDerk,15WestKelloggBlvd.,Suite310,SaintPaul,MN55102”.Claimant:FirstName:LastName:0___ _ _____ _ __PleaseIndicateYourPronouns:She/Her/Hers,He/Him/His,They!Them/TheirsCompanyorBusinessName:—_____ _ _ _____ _IsthisclaimbeingmadebyanInsuranceCompany?YES!Ifyes,whatisyourClaim/FileNumber?IsthisclaimbeingmadebyanAttorney?YES/Ifyes,whatisyourFileNumber?Ifyes,provideyourInsured’s!Client’sName:—StreetAddress:D(flQQLjO5City:State:ZipCode:SS01Daytime/WorkPhone:CellPhone:DateofIncidentorDateDiscovered(MustComplete):Pleasestare,indetail,whathappenedthatpromptedyoutofileaNoticeofClaimForm:—PleasestatewhyorhowyoufeeltheCityofSaintPaulisresponsibleforyourDamages?Pleasecheckthereasonthatmostcloselydescribesthereasonforyoursubmittingaclaim.Pleasenotethedocumentsthatwillneedtobeprovidedwithyourcompletedform.Photographswillbeaccepted.AlldocumentssubmittedbecomethepropertyoftheCityofSaintPaulandshallnotbereturned.EAutomobiledamagefromamotorvehicleaccident:pleaseprovidetwoestimatesforrepairsoractualbillthathasbeenpaid.Automobiledamagefromastreetdefectorpothole:pleaseprovidetwoestimatesforrepairsoractualbillthathasbeenpaid.DAutomobilewastowedandmayormaynothavesustaineddamage:pleaseprovidecopyoftowingticket(ifavailable),receiptfromImpoundLot,andtwoestimatesforrepairsoractualbillthathasbeenpaid.SnowEmergency:pleaseprovidecopyoftowingticket(ifavailable),receiptfromImpoundLot,andtwoestimatesforrepairsoractualbillthathasbeenpaid.Propertydamage:pleaseprovidetwoestimatesforrepairsoractualbillthathasbeenpaid.0Youwereinjuredduringamotorvehicleaccident:pleaseprovidepolicereportnumber,detailsaboutinjury.0YouwereinjuredintheCityofSaintPaul:pleaseprovidepolicereportnumber,witnesses,anddetailsaboutinjury.Continuetopage2ofNoticeofClaimForm,Failuretocompleteandreturnbothpageswillresultindelays.RevisedMarch2023 Thissectionmustbecompletedforallclaims.Isthereapolicereportforthisincident?YES/!NOIfyes,pleaseprovidethepolicereportasenumber:Ifyes,whatlawenforcementagencyresponded?Wheredidtheincidenttakeplace?Pleaseprovdeastreetadess,intersectionornaofcityparkorfacility:ngh*.3idWhatwouldyouliketoseehappentoresolvethisclaimtoyoursatisfaction?- -Weretherewitnessestothisincident?Pleaseprovidenamesandcontactphonenumbers:Forpropertydamageclaims,includingvehicleaccidents.Yourvehicle’sinformation:Year:2_Q1_Make:_±L__Model:Color:LicensePlate#:Statevehicleisregisteredin:Registeredownerofvehicle:S(A‘Ljajj’CiSDriver:Area(s)damagedIfaCityvehiclewasinvolved,LicensePlate14:CoIor:WasthereCityinsigniaonthevehicle?YES/NODriver’sName:Otherpropertydamaged:Forinjuryclaimsofanytype.Whatpartofyourbodywasinjured?——Didyougototheemergencyroomorurgentcare?YES/NOWhere?_ _ ____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Wasmedicaltreatmentreceived?YES/NOWhere?—Firstdayofmedicaltreatment?Areyoustillreceivingmedicaltreatment?YES/NODidyoumissanyworkasresultofthisincident?YES/NOEmployer(s):——Howmuchtimehaveyoumissedfromwork?Ifyouaresubmittingotherdocuments,pleasestatewhatyouareattachingandhowmanypages:Bysigningthisform,youagreethatallinformationprovidedistrueandcorrecttothebestofyourknowledge.PleaseNOTEthatsubmittingafalseormisleadingclaimcanandwillresultinprosecutionunderMinnesotaStatutes.NameofPersoncompletingform:SignatureofPersonsubmittingthisform:RelationshipofpersonsigningtoParmakingtheclaim:Datedocumentisbeingsigned:RevisedMarch2023 INVOICECOTTAGEGROVEBIG0TIRES8647EASTPOINTDOUGLASROADSCOTTAGEGROVE.MN55016-4086(651>458-5738TIRES.THETEAMYOUTRUSTVisitUSonthewebat:www.bigotires.comPaceIInvoiceNo:023026-47308OrderNo:47308Date:04/10/2023Time:0104PMStartedby:JOHNRAKOWIECKIInvoicedby:JOHNRAKOWIECKICust.:SHANNONDANIELS3026-631226Address:City,State,Zip:Phone:(651)303-9172AltPh:Cell:(651)303-9172VehicleInformationYear:2015Make:BMWModel:328SeriesColor:License:NEED(MN>Odometer:123123Engine:4-19972,OLDOHCVIN:Unit:Driver:TirePressureFront:0Rear:0Torque:TPMSWarningLightsOnIncoming:NoOutgoing:NoBillTo:CustomerInstructionsSaveOldParts?NoGiveusyourfeedbackforachancetoMon:hlyPrzes.•aApp.’eProductsWinUpto$400InPrizesO,si*r,.tdocte:y.seesoeysteIc’co,’tetedc!a.andMoreParti____ _DeSoriptTechnicia_QtyUnitPriceTotalPricePIR2639800225/45R1891VPIRELLICINTURATOP7CHEC92.00276.99553.98TireSerial#:FTRYU32I22IFTRYU32122ILABTICBSPLIFETIMEWHEELBALANCE(PERTIRE)CHEC92.0013.9927.98LABTIDMMOUNTANDDISMOUNT(PERTIRE)CHEC92.007.001400CHEC9000000000*ALIGNMENTCHECKREQUIREDINORDERTOHONORCHEC90.000.000.00MANUFACTURER’SMILEAGEWARRANTYCHEC90.000.00000*FREETIREROTATION(RECEVERY5,000MILES)CHEC90.000.000.00*FREETIREBALANCE(RECEVERY10,000MILES)CHEC90.000.00000(NOTINCLUDINGDISMOUNTANDMOUNT)CHEC90.000.000.00*CHEC90000.00000FEEFEETDTIREDISPOSALFEECHEC92.004.008.00*TPMSSERVICEKITMUSTBEREPLACEDONALLCHEC90.000.00000TPMSEQUIPPEDVEHICLESONCEATIREHASBEENCHEC90.000.00000REMOVEDFROMTHEWHEEL*CHEC90.000.000.00RHWTPPABSTIREPROTECTIONPLAN-PRO-TEC+CHEC92.0041.5583.10Thisextendedwarrantycomeswitha3-yearRoadsideAssistance.Call800-351-8545forhelp.Italsoincludesa3-yearwarrantyforfreetirereplacementduetoaRoadHazard.SeetheTireProtectioncontractfordetails.Thiscontractsupersedesanyotherprintedreferencerelatedtotheextendedwarranty.Bysigningthisinvoice,youagreetothetermsandconditions,includingyourrighttocancel,asoutlinedintheTireProtectioncontract.OIL7020KTPMSSERVICEKITCHEC92.009.9919.98Thohn:oianswhoPerformedSer;icesonInvoj.ce[CHECHC:4PiSTQPHERECKLUNCbolasinv9-20220825InvoiceSummaryContinued-Page:1of:2 INVOICEInvoiceNo:023026-47308Pace2COTTAGEGROVEBIG0TIRES1’IIE5OrderNo:473088647EASTPOINTDOUGLASROADS.Date:04/10/2023Time:01:04PMCOTTAGEGROVE.MN55016-4086THEEAMYOURUS(651)458-5738Startedby:JOHNRAKOWIECKIVisitusonthewebat:www.bigotires.comInvoicedby:JOHNRAKOWIECKIVehicleInformationYear:2015Make:BMWCust.:SHANNONDANIELS3026-631226Model:328SeriesColor:Address:License:NEED(MN)Odometer:123,123City,State,Zip:Engine:4-19972.OLDOHCVIN:Phone:(651)303-9172AltPh:Cell:(651)303-9172Unit:Driver:T i r e Pr e s su re F r on t : 0 R e ar :0T orq ue :___ _ __ _ __ _ __ _ __ _ __ _ __ __ _ __ _ __ _ __ _ __ _ __ _ __ __ _ __ _ __ _ __ _ __ _ __ _ __ __ _TPMSWarningLightsOnIncoming:NoOutgoing:NoBillTo:CustomerInstructionsSaveOldParts?NoPartNoDescription_ __ _ __ _ _QtyUnitPriceTotalPriceCren.t‘arceceIpt‘‘Date’Ti’:o.,!iG.’2,2loi:.::,,tardholder:gHA‘iT:peCare:rber-6€2-Teri:110“U——I—0,—tTj)..‘h‘nd”:lEnr:’teth.d:Cha”erenamedabn’:eondsand/ntser’.’icas.if:hle‘: ‘/“f”.r-- ,rerCustomer;ii.thecaroholoersagreementwzthhelsr’Jer.Signature-TherearecCncejjaticr.sa11:-;ed.bo/asinv9-20220825Invoice_SummaryPaymentInvoiceTotalsParts573.96TypeAmountFET0.00VISA****6624Auth$754.13CoreChg000015824Labor125.08WasteDisposal8.00ShopSupplies6.20SalesTax4089Total:754.13 651-451-9721.INVERGROVEHEIGHTS24HourServiceRO.#DATE:DEALER:PRESENTLOCATION:)RKORDER#POLICEHOLD:vsciNoti.1-.RELEASEBY:DELIVERTOI‘BOARDLICARLINONELIBILLTOLOT1LOT2ROWYRMAKEMODELCOLORLiCENSE#OWNER’SNAME-VEHICLENO.-TOWLIRETOWLISERVICECALLLIWINCHLIDOLLYROLLEDLICLEANUPLIOTHERAIRLINELISHAFTLIFUELSURCHARGELISTORAGE:NO.DAYS@PERDAYPAIDOUT:MI.ONCAR:MI.TOWEDIN:ADMINOURDRIVER:AMOUNT)%,TRK#-I,theundersigned,dohereb’ycerfifythatIamlegallyauthorizedandentitledtotakepossessionofthevehicleSUBTOTALdescribedaboveandallpersonalpropertythereininitspresentconditionandagreenofurtherclaimswillbemadeCREDITCARDFEEagainstSouthEastTowing,Inc.NOTRESPONSIBLEFORDAMAGETOVEHICLENotresponsibleforlossordamagetocarsorarticlesleftincarsincaseoffire,theftoranyothercausebeyondourcontrol,SIGNEDDATEj3TAX.lc.ijpI‘—A