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Lo, Kenchi 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 this completed form to the mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint Paul City Clerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”. Claimant: First Name: _Kenchi_______________ Last Name: ____Lo__________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs Company or Business Name: _Young Adult Career Academy – Ramsey County________________________ Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? <_________________________ Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________________ If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________ </ Street Address: _____15152 Quintana Court NW____________________________________________________________ City: ___Ramsey__________________ State: ____________MN__________ Zip Code: _______55303________ Daytime/Work Phone: ________same as cell__________ Cell Phone: ___________763-923-1078_______________ Date of Incident or Date Discovered (Must Complete): 4/5/2023 Time: ______________8:40 AM_______________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___Flat tire from a pothole off the highway 280 exit onto Eustis St while driving to my internship ______________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____Insufficient warning of potholes and space of road to avoid them___________________ 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. Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays. 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: ___________________________ 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: ________________Highway 280 exit onto Eustis St_____________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? _________Reimbursement of tire damage service call and new tire replacement____________________ Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 ____________Yes, Vincente 651-387-9414 and Zachary 651-283-9894_______________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: 2014 Make: ___Toyota______________ Model: ____Camry_____ Color: ____White________ License Plate #: ________NLV351_____________ State vehicle is registered in: ______MN_____________ Registered owner of vehicle: ________Chee Vue_________ Driver: ____________Kenchi Lo_________________________ Area(s) damaged:__________Tire________________________________________________________ If a City vehicle was involved, License Plate #: _______________N/A______________ Color: ____N/A_______________________ Was there City insignia on the vehicle? 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? NO Where? </________________________________________________________________ First day of medical treatment? _____________ Are you still receiving medical treatment? NO Did you miss any work as result of this incident? YES < Employer(s): ___________Ramsey County_________________________________________________________________ How much time have you missed from work? ________1 day_________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages: _____Receipt for tire service, Receipt for tire replacement, and 2 pictures of the flat tire _____________ 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: _____Kenchi Lo_______________________________________ < Signature of Person submitting this form: _________________________________________________ Relationship of person signing to Party making the claim: SELF Date document is being signed: 4/10/2023 Revised March 2023