Maghrak, Lucille ��v�l 1!�L.+
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NOTICE OF CLAIM FORM to the City of Saint Paul, n����� �
Minnesota State Statute 466.05 states that ' ...every person...who claims damages from any municipa/ity...sha/l cause to be presented to the
governing body of the municipaliry within 180 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 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 compteted. If something dces 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 L��/'G Middle Initial,�Last Name /�
Company or Business Name /�--�
Are You an Insurance Company? Yes� If Yes, Claim Number?
Street Addressc'���s �• �� �-�" '�� ( �7
City�//7/� �� State �/1� Zip Code /
Daytime Phone(�i12)�f¢.Z- 2S��Ce11 Phone( ) - £�er�i�gTelephone(�GJ�)Z`�- /�3Z—
Date of Accidend Injury or Date Discovered ��Z���� Time S' �� m pm
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.
O/�i4.41 Sl�C �hc i7'2:e%!'!'LU
Please check the box(es)that most 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/or 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 conies of all applicable documents.
For the claims types listed below, please be 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.
• 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 claims: 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—please complete this section
Were there witnesses to the incident? Yes No nknow (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No 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. Please be as detailed as possible. If necessary,attach a dia ram.
�Q,�bblGS�c� �Q� .��Yi�.G/ G�'J t�t G! _ ��i1�'�PL!/i'��'1?LGe
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Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfactionc�(o0•62 /'��irrl ��c.r.�w�r fey' �i�ie.�C �r5!% l���f�i^
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year /99G Make t0 Model �.��� �r
License Plate Number �i O 'm il/ State /l� Color C�'"G�
Registered Owner %/l �'!'! �'
Driver of Vehicle ��
Area Damaged Fi'l�yt,t.ca�r-G�/fod� Y�
City Vehicle: Year Make Model
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 aoplv
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 ���o-/}�
Print the Name of the Person who Completed this Form: �-1u���� /na�hrit,k- ����
Signature of Person Making the Clai
Revised February 201 I
Lucy Maghrak
3425 East 5oth St.#zo7
Minneapolis MN 554�7
6iz-46z-z5�5
Imaghrak�a gmail.com
June 6 zo�4
TO: City of St. Paul
RE: Expense reimbursement for tire damage due to pothole
To whom it may concern,
On Tuesday April zg at approximately 8AM I was driving east on Ford Parkway, approaching
Fairview Avenue, when I hit one of several potholes on that stretch of roadway. It had been raining
steady the night before and was raining at the time so it was difficult to determine whether there
were potholes or puddles on the roadway. Needless to say I hit a pothole on the right front
passenger side and immediately had a flat tire. I pulled over just east of Fairview Avenue to assess
the damage and it was completely flat. I had an important appointment at work so it was crucial
that I get to work on time, therefore I needed to take a cab.This appointment required that I dress
in professional business attire and therefore I would not have been able to fix my own flat, not to
mention it was still raining at the time.After work, a good friend and a Good Samaritan helped me
replace the flat with the spare tire. I had to stop at the BP on Kenneth and Ford Parkway to get air
in the spare, and afterward stopped at my neighborhood shop to have the spare checked for safe
driving in the morning.This was unforeseen tirr�e and trouble on an average workday. I work at
Metropolitan State University of the East Side of St. Paul and my mechanic at Roy's Service Station
replaced the front tire the following morning, he also suggested that I contact you for
reimbursement.
That stretch of Ford Parkway has since been repaired, but it was in very bad shape in the months
leading up to that incident. Had these potholes been repaired much sooner, my incident and
countless others I'm sure, might not have happened in the first place. I've seen situations where a
car swerves to miss a pothole and nearly hits another car in the process.
I am requesting that the City of St. Paul reimburse me for my taxi ($�9.�0)and tire repair($4�•52)
expenses totaling$6o.6z., and I am including a photocopy of the original receipts.
Thank you for your time and let me know if you require additional information.
Sincerely,
Lucy Maghrak
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