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Loh, Le Yang (2)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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon or other relief demanded.” Please complete this form in its en@rety by clearly typing or prin@ng your answers to each ques@on. If you have addi@onal documenta@on you may add those documents to your submission. You will not be contacted by telephone unless clarifica@on is needed. The claim process for inves@ga@ons can take upwards of four (4) weeks. This form must be signed, dated with all applicable sec@ons completed. Submission is to the Saint Paul City Clerk’s Office. You may email, 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 ____________________________ Last Name _____________________________________________ Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☐ They/ Them/Theirs ☐ Company or Business Name: ______________________________________________________________________________ Is this claim being made by an Insurance Company? If yes, what is your Claim/File Number?: _____________________ Is this claim being made by an AHorney? . If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ Street Address: _________________________________________________________________________________________ City: ____________________________________________ State ___________________ Zip Code __________________ DayMme/Work Phone _______________________________ Cell Phone ____________________________________________ Date of Incident or Date Discovered (Must complete) _____________________________Time _________________________ Please state, in detail, what happened that prompted you to file a NoMce of Claim Form. _____________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ______________________________ Please check the reason that most closely describes the reason for your submi_ng a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submiHed become the property of the City of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: please provide two esMmates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole : please provide two esMmates 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 Mcket (if available), receipt from Impound Lot, and two esMmates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing Mcket (if available), receipt from Impound Lot, and two esMmates for repairs or actual bill that has been paid. ☐ Property damage: please provide two esMmates 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 sec@on must be completed for all claims. Is there a police report for this incident? Yes No If yes, please provide the police report case number ____________________ Revised December 2021 If yes, what law enforcement agency responded? _______________________________________________________ Le Yang Loh No No 1448 Albany Ave Saint Paul MN 55108 515-708-4731- - Pothole damage Pothole not repaired on city road 03/02/2023 1:10 AM - - x x - - Where did the incident take place? Please provide a street address, intersecMon or name of City park or facility. ________________________________________________________________________________________________________ No@ce 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 saMsfacMon? _________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________ For property damage claims, including vehicle accidents. Your vehicle’s informaMon: Year ______ Make _________________ Model ____________________ Color ________________ License Plate # _____________________ State vehicle is registered in ________________________ Registered owner of vehicle ______________________________ Driver ______________________________________ Area(s) damaged ___________________________________________________________________________________ If a City vehicle was involved: License Plate # _______________________________ Color _______________________________ Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________ 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 sMll receiving medical treatment? Yes No Did you miss any work as result of this incident? Yes No Employer(s) _______________________________________________ How much Mme have you missed from work?___________________________________________________________________ If you are submi_ng other documents, please state what you are aaaching and how many pages. ______________________ By signing this form, you agree that all informa3on provided is true and correct to the best of your knowledge. Please NOTE that submiAng a false or misleading claim can and will result in prosecu3on under Minnesota Statutes. Name of Person compleMng form: ________________________________________________ Signature of Person submicng this form: _______________________________________________________________________ RelaMonship of person signing to Party making the claim: ___________________ Date document is being signed _____________ Revised December 2021 2500 John A. Johnson Mem Hwy (near the bus stop) City pays for repairs - 2021 Mazda CX-30 Blue GDC 820 MN Le Yang Loh Le Yang Loh Driver front tire -- - - - - - - - - Receipts - 3 pg Photos - 1 pg Le Yang Loh Self 03/15/2023 Receipt for 1 Tire ($129.05) INVOICE NUMBER INVOICE DATE PAGE PURCHASE ORDER NUMBER ORDER DATE SALES REP. NAME / PHONE EXT.TERMS MAKE, MODEL AND YEAR WHSE PART NUMBER QTYORDERED QTY SHIPPED DESCRIPTION UNITPRICE EXTENSION SHIP TO:BILL TO: INVOICE ALL PAST DUE ACCOUNTS ARE SUBJECT TO A FINANCE CHARGEOF1 1/2% PER MONTH,WHICH IS AN ANNUAL PERCENTAGE RATEOF18%. **********REPRINT********** GROUP KJ74062 3/02/23 1 R1540797928 SHIP METHOD: FEDEX GROUND SHIP-TO PHONE: 651-641-8916 363378-000 363378-000 Loh, Le Yang Loh, Le Yang 1448 Albany Ave C/O Discount Tire Saint Paul MN 55108 2501 1350 University Ave W Saint Paul MN 55104 4001 3/12/23 16:49:56 South Bend, IN 46628-8422 (574) 287-2345 (800) 428-8355Customer Service: Ext. 4360Fax: (574) 236-7707 3/02/23 Nick (ext.4246) PayPal MAZD, CX-30 2.5 TURBO AWD21 MN 305(Rev.11.17) 7101 Vorden Parkway 155HR8EL440OS 1 1 90 215/55R18 BS TUR EL440 *# 119.63 119.63 011757 OLD 011757 95H 2019 STOCK Two Year Road Hazard Included*Road Hazard ID: 550014500700 REGCARDR 1 1 Tire DOT Number registration N/C REGISTRATIONR has been filed electronically FIND WARRANTY DETAILS @ WWW.TIRERACK.COM/BS0121 *Customer advised mixing tire types/sizes, or new and partially worn tires may cause unpredictable handling or loss of control in some driving situations *Recommend installing new/deeper tread tires on the rear axle to help prevent oversteer in inclement weather conditions *Customer is aware of possible drivetrain wear or failure when replacing less than four matched tires. Subtotal 119.63 Sales Tax-Minnesota 9.42 -129.05 Total Payment -129.05 * * * * C O N T I N U E D O N N E X T P A G E * * * * Receipt for installa@on ($25) DISCOUNT TIRE LE YANG LOH 3/03/2023 1:57 PM 1448 ALBANY AVE SAINT PAUL, MN 55108 515.708.4731 (M) 2021 MAZDA CX-30 18"BASE SELECT MNM 06 1350 UNIVERSITY AVE W SAINT PAUL, MN 55104 651.641.8916 Salesperson 444 LUIS A A MIies: 19,519 Torque Specs: 105 Invoice II 6378203 Estimated Completion Time 03:00 PM \ .J\rUcle 80085 NRM Qty Description 1 lABOR lABOR CJEM INFLATION F:36 R:36 replace LF vith hri turanza in bay 6 ·rare \o home '1,lL T PATTERN: 5-114.3 l'J0224 1 WASTE TIRE rrnM DISPOSAL FEE ,PPOINTMENT: 03-03-2023 1:45 PM Tkn/f XXXXXXXX4176 Athll 09739D EEI Prlc.e. 22.00 3.00 Sub Total: 25.00 Sales Tax: .00 Sales Total: 25.00 Tendered: Tendered Today: 25.00 25.00 Tendered Total: 25.00 www.dlscounltlre.com/llre -reg Isl ration Amount 22.00 3.00 (VIS) Receipt for Wheel Alignment ($149.77) Pothole