Xiong, Doua
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 ______Doua__________________ Last Name _________Xiong_______________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His <☒_ They/ Them/Theirs ☐
Company or Business Name: ______n/a________________________________________________________________________
Is this claim being made by an Insurance Company? YES If yes, what is your Claim/File Number?: <____A00004863955____Erie Insurance_________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name _____Doua Xiong____________________________________________
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Street Address: _____9379 S. 35th St__________________________________________________
City: ___Franklin_________________________________ State ____WI_______________ Zip Code ____53132______________
Daytime/Work Phone _____414-458-8132__________________________ Cell Phone ____414-458-8132___________________
Date of Incident or Date Discovered (Must complete) 3/26/2023Time __________12:30 AM_____________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _I am filing this claim due to damages sustained on my vehicle tires and rims after traveling
on your city streets ladened with unfilled potholes. On the night of the 25th going into the 26th, we were traveling northbound on White Bear Ave. We were traveling at speed limit
in the right lane of the street when passing the lights at the intersection of Frost Ave and White Bear where we encountered a large pot hole that was extending from the east side of
Frost Ave into the right lane of White Bear Ave. Due to vehicles also traveling in the left lane, we were not able to avoid this pot hole. Almost immediately, it was apparent that
we were losing tire pressure and then received a severe tire pressure loss alert from the vehicle within 1/2 mile. We then turned west off of White Bear Ave at the next intersection
onto Cope Ave and found a safe location on the 2200 block of Flandau Ave to park our vehicle. Upon inspection of the tires, there was a notable gash on the right passenger tire< and
tearing/abrasions on the others. We attempted to fill the tire with a portable pump but was unsuccessful due to the size of the hole in the tire. After several delays with the tow
company, our vehicle was eventually able to be towed to Discount Tire at 2570 White Bear Ave N. Maplewood, MN later that evening. <However, due to the specialized tires on our vehicle,
it needed to be towed to another tire shop the next day. At this shop, they determined that all 4 rims also sustained damage from the pot holes.______________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___Public city streets are the responsibility of the city to maintain in order to ensure safe
vehicular travel. Therefore, potholes are the responsibility of the city to fix in order to prevent property damage such as this. Due to delayed filling/repair of this particular pothole,
our vehicle sustained unnecessary damage resulting in a substantial financial burden to repair/replace. This was no<t the only pothole we encountered, there were many potholes throughout
many of the city streets that we had traveled on thus the assessed damage to all 4 tire sidewalls.
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.
☒ 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.
____East intersection of White Bear Ave and Frost Ave _St. Paul, MN___________________________________________
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? ____I am seeking reimbursement of all repair costs. Breakdown of cost are as follows with receipts attached:New
Tires: $1100 Towing: $219.32 for the 1st towing and additional unknown cost for the 2nd towing (paid by our insurance) Alignment: $179.99
Were there witnesses to this incident? Please provide names and contact phone numbers. Shoua Hang 414-699-4219, Jenny Yang 414-587-7771_____________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year ___2020___ Make __BMW________ Model ____X7 M50i_________ Color _____Blue______
License Plate # ___SJX5X8_______________ State vehicle is registered in ______WI__________________
Registered owner of vehicle _____Shoua D Hang____________ Driver ___________Doua Xiong_____________________
Area(s) damaged : All 4 tire sidewalls with right passenger tire completely punctured_______________________________
If a City vehicle was involved: License Plate # ____________n/a___________________ 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? __________n/a________________________________________________________________
Did you go to the emergency room or urgent care? 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. ___ 1st tow receipt, Tire replacement receipt, Alignment receipt and photos of pothole
which was filled on 3/27/23. Total pages: _5__________________
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: _____________Doua Xiong___________________________________ <
Signature of Person submitting this form: ____Doua Xiong________________________________________________
Relationship of person signing to Party making the claim: ___________________
Date document is being signed 3/27/2023
Revised December 2021