Khang NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that" ...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within t 80 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim, and the amount af compensarion being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed, and both pages completed. If something does not apply, write `N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ZER Middle Initial N/A Last Name KHANG ��`��-�;�;ED
Company or Business Name NJA 0,14
Are You an Insurance Company? Yes� If Yes,Claim Number? N/A
LERK
Street Address 350 STEVENS STREET WEST
City SAINT PAUL State MINNESOTA Zip Code 55107
Daytime Phone(651 )373 -8715 Cell Phone(651 )373 -8715 Evening Telephone(651 )373- 8715
Date of Accidend Injury or Date Discovered 02/18/2014 Time 8:00 am�
Please state, in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. PLEASE SEE
ATTACHED.
Please check the box(es)that most closely represent the reason for completing this form:
O y vehicle was damaged in an accident O My vehicle was damaged during a tow
��Viy vehicle was damaged by a pothole or condition of the street O My vehicle was damaged by a plow
O My vehicle was wrongfully towed and/or ticketed O I was injured on City property
O Other type of property damage—please specify
O Other type of injury—please specify
In order to process your claim yc�i� need to include conies of a11 agplicable documents.
For the claims types listed below, please he sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage c[aims: two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims —glease complete this section
Were there witnesses to the incident? Yes �1Qo Unknown (circle)
Provide their names,addresses and telephone numbers�l�lA
Were the police or law enforcement called? Yes � Unknown (circle)
If yes, what department or agency? N/A Case#or report# N/A
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. ON JOHNSON PARKWAY
HEADING SOUTH BETWEEN E. AMES AVE AND CASE AVE UNDER THE RAILROAD TRACKS.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. $1302.99: FOR TOW,RIM AND TIRES REPLACEMENT AND ALIGNMENT.
Vehicle Claims —please complete this section O check box if this section does not apply
Your Vehicle: Year 2011 Make LEXUS Model IS 250 AWD
License Plate Number 560-GCC State MN Color BLACK
Registered Owner ZER KHANG
Driver of Vehicle ZER KHANG
Area Damaged PASSENGER SIDE FRONT RIM AND FRONT AND REAR TIRES
City Vehicle: Year N/A Make N/A Model N/A
License Plate Number N/A State Color N/A
Driver of Vehicle(City Employee's Name)N/A
Area Damaged N/A
Iniurv Claims —please complete this section �check box if this section does not auply
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
�Check here if you are attachin�more pages to this claim form. Number of additional pages � .
By signing this form, you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed 03/O1/2014
Print the Name of the Person who Completed : ZER KHANG
Signature of Person Making the Claim:
Revised February 2011
NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota(AttaChment)
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please
indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible
for your damages.
On February 18, 2014 at or around 8:OOpm, my wife and I were returning home from grocery shopping
and were traveling southbound on Johnson Parkway when we hit a group of potholes that were located
under the railroad tracks between E.Ames Ave and Case Ave,just passed "Hmong Village shopping
center".As soon as we hit the pothole, I noticed our vehicle pul�ing to the right and immediately thought
we had a flat. I then pulled into the SuperAmerica gas station located on the corner of Johnson Parkway
and 7"'and attempted to put air into the front passenger side tire but the tire would not inflate or hold
any air and I could hear the air seeping out. 1 also checked the rear passenger side tire as well and
noticed it was also going flat.With two tires begin flat, I was unable to put a spare tire on and
proceeded to call a tow truck.The tow truck arrived and we had the vehicle towed to Maplewood
Toyota to assess the damages and it was determined that that both the tires on the passenger side were
punctured and that one of the rims was damaged and not repairable.After the tow and repairs and
replacement,the total cost to restore our vehicle came to$1302.99.
My wife and i feel the city of Saint Paul is responsible for the damages to our vehicle due to the potholes
not being fixed.We fee�we would not have incurred this damage if the pothole was covered
up/repaired or perhaps if there was a sign,forewarning the severity of potholes on certain city streets.
ZerKhang
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CUSTOMER #: los2so 830447 MAPLEWOOD TOYOTA, INC.
2873 HWY 61 NORTH
*INVOICE* MAPLEWOOD, MN.55109
ZER KHANG (651)482-1322
350 STEVENS ST W DUPLICATE 3
SAINT PAUL, MN 55017 PAGE 1
HOME:651-373-8715 CONT:651-373-8715
BUS: 651-646-1706 CELL: SERVICEADVISOR: �5�o TIFFANY YANG
COLOR YEAR MAKE/MODEL VIN UCENSE MILEAGE IN/OUT TAG
BLACK 11 LEXUS IS250 JTHCF5C26B5047205 560GCC 36893 36893 560GCC
DEC,DATE PROD.DATE WARR'.EXP: PROMiSED PO NO. RATE PAYMENT INV.DATE
OlFEB14 D WAIT 24FEB1'4 0. 00 CP 26FEB14
R.O.OPENED READY OPTIONS: SOLD-STK:P12181
22 :46 18FEB14 17:44 26FEB14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
A C/S HIT 'A POTHOLE AND NOTICED THE PASSENGER FRONT & PASSENGER REAR
TIRES ARE NOW LEAKING. PLEASE CHECK ALL RIMS&TIRES FOR
DAMAGE/LEAKS AND REPAIR IF REPAIRABLE
99 ALL TIRES AT 6/32nds. VEHICLE IS AN AWD
VEHICLE AND REQUIRES ALL 4 NEW TIRES DUE TO
POSSIBLE DAMAGE TO DIFFERENTIALS.
7659 C 0 . 00 0.00 0 .00
36893 TECH #7659 PUT SPARE ON PASSENGER FRONT. WHEN CUSTOMER
BROUGHT IN TIRES TO HAVE TIRES INSTALLED, WE FOUND THAT THE PASSENGER
FRONT RIM IS BENT. ORDERED A NEW WHEEL-NEW WHEEL IS NOW ON THE
PASSENGER REAR. CUSTOMER REQUEST TO,,���.�'�'��.;:�.,._OLD TIRES ON THE DRIVER
SIDE. CUSTOMER REQUESTS TO KEEP, O�;;D' �tINI, .,WHT�� �S,::�OXED UP AND IN THE
BACKS EAT. .:'. ;
***************,�,��,*:*******��***-�*******��a�**********
B** C/S INSTALL ALL 4 NEW '�I����I�STOMFR. HAS,;TIRES„,:I`�Ub7`�'&BALANCE
CUSTOMER TIRES. '" ' '
TIRE4 INSTALL 4 TIRE�,,'NIOUNT z�.=���'`���F�i��-'��.LVE
STEMS,TIRE DISPflSAL-INCLUDESE :I�OA17 HAZ/FREE
ROTAT I ON , ' s 4 ;
304 C 1.6tk.=''-: 80. 00 80.00
::.. : ^ :;,
99 NEW RIM/WHEEL IS ON°�T�iE PASSEN(�R RFs`�iR. �
99 MISC,SUBLET �c LIC#: 12��5�678`9
� C 0 . 00 i. :. _ : � ;�� �� �0 .00 0 .0�0
.....
1 42611-53330 WHEEL . 556 .23 556 .23 556 .23
****************************************************
C** ALIGN ALL FOUR WHEELS TO SPECS
ALI ALIGN ALL FOUR WHEELS TO SPECS
304 C 1.40 99.95 99 .95
36893 COPY OF ALIGNMENT SPECS ATTACHED.
****************************************************
CUSTOMER PAY ENVIRONMENTAL, DISPOSAL, AND SUPPLIES FEE FOR REPAIR � 14 .40 a-°�O-��
ao a
ON BEHALF OF SERVICING DEALER, I HEREBY CERTIFY THAT THE STATEMENT OF DISCLAIMER DESCRIPTION ,
INFORMATION CONTAINED HEREON IS ACCURATE UNLESS OTHERWISE The tactory warranry constitutes all LABOR AMOUNT 17 9.9 5
SHOWN. SERVICES DESCRIBEDWERE PERFORMEDAT NO CHARGE TO �„ethsa�e aof thie i e�m\itemse The PARTS AMOUNT 5 5 6 .2 3
OWNER.THERE WAS NO INDICATION FROM THE APPEARANCE OF THE Seller hereby expressly disclaims all
VEHICLE OR OTHERWISE,THAT ANY PART REPAIREDOR REPLACED werranties either express or GAS,OIL,LUBE O .OO
UNDER THIS CLAIM HAD BEEN CONNECTED IN ANY WAY WITH ANY implied, induding any implied SUBIET AMOUNT O .O O
ACCIDENT, NEGLIGENCE OR MISUSE. RECORDS SUPPORTING THIS warranty ot merchantabiliry or
CLAIM ARE AVAILABLE FOR(1) YEAR FROM THE DATE OF PAYMENT fitness tor a particular purpose. MISC.CHARGES 14 .4 O
NOTIFICATION AT THE SERVICING DEALER FOR INSPECTION BY Sel�er neither assumes nor
MANUFACTURER'S REPRESENTATIVE. authorizes any ather person to TOTAL CHARGES 7 5 0 .5 8
assume for d any liability in
connection with the sale of this DISCOUNTSICOUPONS ']rj .��
itemlitems. SALES TAX 3 9.6 3
(SIGNED) DEALER,GENERAL MANAGER OR AUTHORIZED PERSON (DATE) CUSTOMER SIGNATURE pLEASE PAY
THIS AMOUNT 715.21
CapyrqM2000�DP.lnc SERVILEINVOICEM2%313C CUSTOMER COPY