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Youngquist (2) RECEivE� MAR 2 7 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minn�s6�a� CLERK Minnesota Sta/e Sta�ute 466.05 stutes that "...every person...w/to clnims ctmnuges from uny�nunicipality...slTall cause to be presented to the governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensntion 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 of compensation 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 � � � SS G'l Middle Initial�Last Name_�.n��6,� �S -r' Company ar Business[Vame �--'--' Are You an Insurance Company? Yes N/� If Yes,Claim Number? --- Street Address ( �9�ti�� ✓u''Ixl�'�l�'''-i'`---�-'��° City�--� , � --t State // .f� Zip Code �"-�' � il�(j Daytime Phone( ) - Cell Phone(�)��_Evening Telephone( ) - 653 Date of Accidentl Injury or Date Discovered Time��Qam/ r� 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. ��u a_v d�ra-�'v,'vc� �61�1:�Ch rsv� G��rlp.PGtfk.c� �-v��., x4,(�.��.. {-�-�4 _�4� �- , 'P�.�..e _ �"V-e'9 „�r�� .-e' C-� �v-P� 2 -��—� vi-L S � ,ni a �-� 1�-1�—�tAi► `�"�-�3.--�1Z� �---."--�{��.L ��-x�{ � �vrr�� a.e_:� d • � -�. - �y a Plea�se heck the� b�s�that if�bst closely represent the reason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow �My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/ar ticketed ❑ I was injured on City property ❑ Other type of property damage-please specify ❑ Other type of injury-please specify In order to process your claim vou need to include copies of all applicable documents. For the claims types listed below,please be sure to include the documents indicated ar 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 biils 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 propeRy damage claims: two repair estimates if the damage exceeds$500.00;ar 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-please comulete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes �N Unknown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Ple se be as detailed as possible. If necessary, attach a diagram. �'�.P;l/-� " .�J�.C��-�' �'n,� � G��_ '�i—U G�'�2 L� , � �I.C�i..�—f Please in �cate the amou�t�ar�ekin in compensation or what you would like the ity to do to resolve this claim to your satisfaction. �`"� �- �� Ge.C'C�c.�--_C -�rl�- 1"U'o �pt.�,yc..at�-P� .�--�yi� �+vu-s . Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year 2l�b�Make C,�� » Model License Plate Number,� d,��L�'�-t33 State�(�Color ��l�� Registered Owner i Driver of Vehicle � Area Damaged � � �. City Vehicle: Year Make Model �a�'� 'n� License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims please complete this section �check box if this section does not applv 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 attaching 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 ?��2� � 1 � Print the Name of the Person who Completed this Form: S ` Signature of Person Making the Claim: Revised February 201 I City Clerk 15 West Kellogg Boulevard, 310 City Hall Saint Paul, MN 55102 March 2stn 2014 To Whom It May Concern, My name is Alyssa Youngquist, and I am a home owner at 1786 Wordsworth Avenue. On Sunday, March 10th at approximately 10:30pm, I was driving south on Cleveland Avenue and merged left onto St. Paul Avenue towards my home. My car,a 2008 Saturn Aura in good condition, hit a spot in the road that was covered in potholes. Because of the poor street I�ghting in this area, I was not able to see any potholes on the road as I drove through. Looking at this ro�d the very next day,the intersection of Cleveland Avenue South and St. Paul Avenue appeared to b�completely covered in potholes with no clear path for safe driving. Both of my car's front tires went flat,and both front tire rims were damaged. I was able to get these two flat tires repaired on March 11`h at tires Plus (300 Snelling Avenue) at a cost of$59.54. I would like to submit this$59.54 bill to the City of St. Paul for reimbursement. I have enclosed a "Claim Form" from the City of St. Paul, a copy of the bill from Tires Plus, and copies of my two front tires that were damaged. . I appreciate your attention to this matter. Thank you! C��.� .�-.��- ��-��- Alyssa Youngquist alyssajyoungquist@gmail.com 651.343.4653 1786 Wordsworth Avenue Saint Paul, MN 55116 � ". Product Sesrch �n Off� Home � Locations � Contact Us � Espanol � Online Securit�Guarantee Wells Farc�o C�n�ir�e�' AccountsBill PavTransfersBrokerageAccount ServicesMessa�es & AlertsProducts& Offers Account SummaryAccount ActivitvMv Mone�� MapStatements & Documents Account Activity �� CUSTOM MANAGETAENT(W1A)XXX�(X503E. � � ACCOUrit --�--� Date : Description ne�osits/ Withdrawals/ Credits Debits Posted '�'ransactions CHECK CRD PURCHASE 03/11 TIRES PLUS 244226 03/13/14SAINT PAUL MN 434257XXXXXX7953 $59.54 384070778416057 ?MCC=5532 U91000019DA Totals $59.54 , , _ :. �, . o_ _ .�. , _,. ,_ _;__.,_.. _,� :.::.� Alyssa Youngquist Claim/Two Flat Tires from Pothole 3/10/2014 „�.'� �3. . � ;�; 1 yRv='��','��. � � 3 I II � I '"i�i4i.ii,i, i�a t,�� I i �I II�:,:, �..Y�'�k„�' ... �; 'a. ' 4i' IIiil�� I illl �� I I� '3„ 9 a£ � ��rr°' Y��y4bil��i�l� ,u,�l�II� iu"i i � � Page 1 of 3 .. . _ -r-t,. .. :'�`;w....�.. ,�. .. . . .. , � ,_ . Iir,- .._'.x. . � . � . .a .= '_' ''"'_ .',...._ . - ... ' T..'..,.- y .•.' , �'• �: . _.�. _ " ' Alyssa Youngquist Claim/Two Flat Tires from Pothole 3/10/2014 � �_ T �, �f` z., b � � �,,, � . �: �' ,�: ��`.- � �. C �, a %� ;;;�.. ,. f'., � J I i�, i . �, llv kk-' '�. � �' �: .. � : .. .,.. � �,:, s �IIIICII ; 1��, � � � '„�RlshWr�ii ��t � :� ,.� ��`, �, �� r e .��,�,'�. �y�j�l ri� ?�S � ��" �r k�, F(', Page 2 of 3 �, _ . � . _ �...._ _._ _ �� - ,f rn , ....� � . . - i _ _ : : .._ t. ,�, .,.. . _ � r �: ,,.�. ,. - y,. :_- . . ;�._. � � Alyssa Youngquist Claim/Two Flat Tires from Pothole 3/10/2014 �.. ,� r �*a� t� � IV v � ��'= a� � �� A�� , � �. ..�,'�. �� a.-.. �`:,: ',;r�t',a�� .4i° �� . a: � a. �=,,� �, � �'=, � ''F I'�� : � �7k�•� �.N � ��I� � Il�pr��i��,��A ��a��..=r ��", %'"s� �' �''��': � � ,, �. I�i�I, 3 ��i.. \'� ��•.� .i�u� . v , ',..4 ' �it°�� ._=.,,.."�f,'. Page 3 of 3