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Meyer, Leslie 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 municipality…shall 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 compensation or other relief demanded.” Please complete this form in its entirety by clearly typing or printing your answers to each question. If you have additional documentation you may add those documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission is to the Saint Paul https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may < mailto:cityclerk@ci.stpaul.mn.usemail, fax (651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102” Individuals: First Name ____________Leslie________________ Last Name _______________Meyer_______________________ Please Indicate Your Pronouns: She/ Her/Hers X He/Him/His <☐_ They/ Them/Theirs ☐ Company or Business Name: ______________________________________________________________________________ Is this claim being made by an Insurance Company? </w:t </w:t></w:r If yes, what is your Claim/File Number<?: _____________________ Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ </ Street Address: 1148 James Ave_________________________________________________________________________ City: St. Paul___________________________________ State:MN ___________________ Zip Code _55105_________________ Daytime/Work Phone 612-716-0807_______________________ Cell Phone 612-716-0807______________________________ Date of Incident or Date Discovered (Must complete) 2/27/2023Time __9:15 pm___________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. My vehicle hit a pot hole on the entrance ramp to 35E at Kellogg Blvd_________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? The pot hole should have been patched or filled by city crews__________________ Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will need to be provided with your completed form.< Photographs will be accepted. All documents submitted become the property of the City of Saint Paul and shall not be returned.< ☐ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid. X Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid. ☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Property damage: please provide two estimates for repairs or actual bill that has been paid. ☐ You were injured during a motor vehicle accident: please provide police report number, details about injury. ☐ You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury. This section must be completed for all claims. Is there a police report for this incident? NO If yes, please provide the police report case number ____________________ Revised December 2021 If yes, what law enforcement agency responded? _______________________________________________________ Where did the incident take place? Please provide a street address, intersection or name of City park or facility. The entrance ramp to 35E south at Kellogg Blvd__________________________________________________________ Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.< What would you like to see happen to resolve this claim to your satisfaction? _Reimbursement from the city for the replacement of 2 automobile tires_____________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers. Mike Meyer 612-716-0840 Jay Phillips 651-341-5819 Both were passengers in the car______________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year 2014_ Make Honda________ Model __Accord_________ Color Gray_________ License Plate # ______CVH 218_______________ State vehicle is registered in ____________MN____________ Registered owner of vehicle Michael & Leslie Meyer_______________ Driver Leslie Meyer_______________________ Area(s) damaged _Front Right Tire__________________________ If a City vehicle was involved: License Plate # _______________________________ Color _______________________________ Was there City insignia on the vehicle? Yes No Driver’s Name </w_____________________________________________ Other property damaged: ___________________________________________________________________________________ For injury claims of any type. What part of your body was injured? __________________________________________________________________________ Did you go to the emergency room or urgent care? Yes No Where? _________________________________________________ Was medical treatment 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 No Employer(s) <_______________________________________________ How much time have you missed from work?___________________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages. _1 Paid bill and 2 photos 3 total pages____ 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 will result in prosecution under Minnesota Statutes. Name of Person completing form: ___Michael Meyer_____________________________________________ < Signature of Person submitting this form: _Michael Meyer_____________________________________________ Relationship of person signing to Party making the claim: Spouse Date document is being signed 3/8/2023 Revised December 2021