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McBride, KelseyToo whom it may concern, I originally mailed this document in on march 18th 2023 but I haven’t heard a response from anyone so I am emailing it in with all the same documents. Please reach out to me if you have any questions or concers I can be reached by phone at 612-409-5299 you can text or call and please feel free to leave a voicemail if you get no answer, or you can email me at either smithkelsey46@gmail.com <mailto:smithkelsey46@gmail.com> or chadaranda55@icloud.com <mailto:chadaranda55@icloud.com> . I look forward to hearing from someone soon. Thank you, Kelsey McBride. 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 City Clerk’s Office <https://www.stpaul.gov/departments/city-clerk> . You may email <mailto:cityclerk@ci.stpaul.mn.us> , 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 __KELSEY Last Name MCBRIDE __________________________________ 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? NO 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: 333 ARBOR ST _______________________________________________________ City: SAINT PAUL __________________________ State MN _________ Zip Code 55102 Daytime/Work Phone _______________________________ Cell Phone ____________________________________________ Date of Incident or Date Discovered (Must complete) MARCH 16TH 2023___________________Time 10:11PM ____________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Timeline of events for flat tire on 03/16/2023 Picked my sister up from work at exactly 10pm work address is 1925 Norfolk ave Saint Paul mn, We proceeded to go down west 7th and turned right at the west 7th and st.Clair intersection witch is about 11 minutes away from 1925 Norfolk ave (time is about 10:11pm) then proceed to go towards the smith bridge, we’re on cliff street we hit a very large pot hole, by the time we reached the stop sign to turn on to the smith bridge (high bridge) the tire signal came on. We proceed to go up smith street entill we hit the stop sign at butler and smith at witch we heard what sounded like a flat tire so we stopped to look and see if it was us witch in fact it was. We proceeded to go to the speedway on Robert street in west st.Paul witch is about another 11 minutes from west 7th st and stclair ave/ cliff st at witch we got there at about 10:22pm and I had gotten out of the car taken a picture of the tire at 10:23pm, proceeded to try and put air in it but the air pump at speedway on Robert st did not work. At witch time I called my mother in law at 10:29pm she had sent someone to help but he was in a stollen vechial so the cops arravied at 10:50pm to arrested him and tow the vehicle, one of the officers at the seen said you know you have a flat tire we then said yes we know we just can’t change it so the officer offered to change it, but was not able to because I didn’t have all the tools. During all of this o was on the phone with my mother in law the call I made out going to her was at 10:50pm witch lasted 3 minutes in witch she told me she was going to be on the way with her husband to change it she called me at 11pm to say she was pulling up. On 03/17/2023 I went to discount tire on Robert st in west Saint Paul to replace the tire at witch time they told me there was slight damage to the rim, and they replaced the tire see attached documents regarding that with price and time stamp. See attached photos of pot hole, flat tire, calls to my mother in law, screenshot of the video from the officers at the speedway on Robert st in west Saint Paul, gps of estimated eta to each destination ( I used coopers on west 7th street as a location for the intersection of west 7th and st.Clair/cliff to show eta, then coopers to speedway in west Saint Paul on Robert street to show eta as well. Please state why or how you feel the City of Saint Paul is responsible for your Damages? BECAUSE I WAS DRIVING DOWN THE ROAD AND IF YOU LOOK AT THE PHOTOS ATTACHETED YOU WILL IN FACT SEE THAT THIS VERY POT HOLE REACHS ALL THE WAY ACROSS THE STREET AND IS AT LEAST 6INCHS DEEP, AND I HAD TO PRIOR PROBLEMS WITH THE TIRE OR MY CAR ENTILL I HIT THE POT HOLE AND AS SOON AS I HIT IT AND GOT TO THE STOP SGIN MY TIRE SIGNAL CAME ON AND THE STOP SIGN FROM THAT POTHOLE IS ABOUT 300 FT. THERE IS MUTUPLE PHOTOS ATTACHED OF THE POT HOLE AND A TIME STAMPS OF EVENTS. 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? Yes No If yes, please provide the police report case number NO THERES WAS OFFICERS IN WSP THAT OFFERED TO HELP BUT DIDNT KNOW HOW TO CHANGE THE TIRE LOOK AT SCREENSHOTS OFTHE VIDEOS THAT SHOW THE POLICE THERE AT TIME.____________________ Revised December 2021 If yes, what law enforcement agency responded? WSP PD________________________________ Where did the incident take place? Please provide a street address, intersection or name of City park or facility. ON CLIFF ST AND THE CROSS STREETS OF SUPIORIUR AND GOODHUE, THE WSP PD WERE RESPONDERING TO A CALL OF A STOLEN VECHILE AT THE SPEEDWAY ON ROBERT ST THATS WERE THE PHOTOS AND SCREENSHOTS CAME FROM. 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 WOULD LIKE TO SEE THE POT HOLE THAT COVERS A WHOLE STREETS WITH AND GOSE DOWN ABOUT SIX INCHS FILLED, ALLONG WITH I WOULD LIKE TO BE REIMBURSED FOR HAVING TO SPEND ALMOST 300 ON A TIRE AND SERVCE AND HAVING A RIM STRAIGHTENED OUT SO I COULD STILL DRIVE ON IT BECAUSE I WASNT ABLE TO BUY A WHOLE NEW RIM. Were there witnesses to this incident? Please provide names and contact phone numbers. MY SISTER SADIE MCBRIDE 763-340-5038 For property damage claims, including vehicle accidents. Your vehicle’s information: Year 2018 _ Make _FORD Model ____FUSION ___ Color _BLACK ______ License Plate # _____________________ State vehicle is registered in __MN______________ Registered owner of vehicle ____KELSEY MCBRIDE ___________ Driver _____KELSEY MCBRIDE ________________ Area(s) damaged ________FRONT PASSSANGER TIRE ALONG WITH RIM ______________________________________ 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 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.YES PHOTOS 12 PHOTOS AND A PDF OF MY BILL FOR MY 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: ____KELSEY MCBRIDE ________________________________ Signature of Person submitting this form:__KELSEY MCBRIDE Relationship of person signing to Party making the claim: ____ME PERSONALLY ___________ Date document is being signed ____MARCH 17TH 2023 _____ KELSEY MCBRIDE KELSEY MCBRIDE 202 WEST 7TH SAINT PAUL, MN 55102 651.500.8161 (H) VIEW SALES INVOICE DISCOUNT TIRE Plate#: BRG635 Miles: 56,646 Torque Specs: 100 3/17/2023 11:55 AM Invoice # 5904152 . . . . . . 2018 FORD FUSION 17"BASE SE MNM 21 1540 ROBERT ST S WEST ST PAUL, MN 55118 651.306.9910 Salesperson 100 DARRYL W Estimated Completion Time: -------------------------------------------------------------------------------- Article Qty Description FET Price Amount -------------------------------------------------------------------------------- 37582 1 235 /50 R17 96V SL BSW 170.00 170.00 NRM YOK AVID TIRE MILEAGE WARRANTY: 65000 BOLT PATTERN: 5-108 INFLATION F:33 R:33 80017 1 CERTIFICATES FOR NRM REFUND, REPLACEMENT For tire certificate details, see ASCEND GT www.discounttire.com/customer-service/certificates <http://www.discounttire.com/customer-service/certificates> 25.85 3.00 22.00 25.85 3.00 22.00 80224 NRM 80219 NRM 1 WASTE TIRE DISPOSAL FEE 1 INSTALLATION & LIFE OF TIRE MAINTENANCE Terms and Conditions can be found at www.discounttire.com/customer-service/invoice-terms <http://www.discounttire.com/customer-service/invoice-terms> REPLACE RF TIRE IN TRUNK PUT SPARE AWAY PLEASE AND THANK YOU... 01:15 PM When replacing less than four tires, Discount Tire recommends that the new tires will be placed on the rear axle of the vehicle . . . . . The tire and/or wheel you have chosen is different from the original equipment provided with your vehicle and may change its handling or stability characteristics. Further information is available from your Discount Tire salesperson. Sub Total: Sales Tax: Sales Total: Tendered: 300.00 Tendered Today: 300.00 (CSH) 220.85 12.97 233.82 Tendered Total: Change: 300.00 66.18 . . . . Revised December 2021