Yang, SonnyNOTICE 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 bepresentedto the governing body of the
municipality within 180 days after thealleged loss or injury isdiscovered a notice statingthe time,place,andcircumstances thereof,and theamount of compensation
or other reliefdemanded.”
Please completethisform inits entirety by clearly typingor printing your answers to eachquestion.If you have additional documentation,you may add those
documents to yoursubmission.Youwill not becontacted by telephone unless clarification is needed.The claim processfor investigationscan take upwards of
four (4)weeks.Thisform must be signed,dated with all applicablesectionscompleted.Submission this completed form to the Saint PaulCity Clerk’sOffice by
email (cityclerk@ci.stpaul.mn.us),fax (651-266-8574)or mail addressed to “Saint Paul City Clerk,15 West Kellogg Blvd.,Suite310,Saint Paul,MN 55102”.
Claimant:First Name:__Sonny_________________________Last Name:_____Yang_____________________________________
Please Indicate Your Pronouns:☐She/Her/Hers,☐(X)He/Him/His,☐They/Them/Theirs
Company or Business Name:___________________N/A_______
Is this claim being made by an Insurance Company?YES /(X)NO If yes,what is your Claim/File Number?
_________________________Is this claim being made by an Attorney?YES /(X)NO If yes,what is your File Number?
_______________________________________If yes,provide your Insured’s/Client’s Name:
_______________________________________________________________________Street Address:
_______________________________________________________________________________________________City:
______________________________________________State:________________________Zip Code:___________________
Daytime/Work Phone:_7632021648______________________Cell Phone:_7632021648___________________________________
Date of Incident or Date Discovered (Must Complete):__4/15/2023_____________Time:___________8:10 PM________Please
state,in detail,what happened that prompted you to file a Notice of Claim Form:_________Pot hole popped my front tire and
made a damaged on my rim.(driver side).____________________Please state why or how you feel the City of Saint Paul is
responsible for your Damages?_____________________Not filling in the pot hole on that street,it’s crazy how many there
are._______________
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.
Continue to page 2 of Notice of Claim Form.Failure to complete and return both pages will result in delays.Revised
March 2023
This section must be completed for all claims.
Is there a police report for this incident?YES /NO (X)
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:___Ruth St N by the
_Eastern Heights Lutheran Church_______________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?_________Would like to get reimburse for my
tire.___________________________________________________________________________________________________
Were there witnesses to this incident?Please provide names and contact phone numbers:_Yes,my wife her name is Emily Lor,
contact number is 7634386015_______________________________________________________
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year:_2004________Make:____Lexus_____________Model:_______IS300___________Color:
_______Silver___________License Plate #:__________NDG 598_______________State vehicle is registered in:
____________Minnesota_______________Registered owner of vehicle:______Sonny Yang_______________________
Driver:____Sonny Yang______________________________________Area(s)damaged:____Driver side
tire/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?_No________________________________________________________________
Did you go to the emergency room or urgent care?YES /NO (X)Where?_______________________________________________
Was medical treatment received?YES /NO (X)Where?_____________________________________________________________
First day of medical treatment?_____No________Are you still receiving medical treatment?YES /NO
Did you miss any work as a result of this incident?YES /NO (X)
Employer(s):____________________________________________________________________________________________
How much time have you missed from work?__________________None________________________________________________
If you are submitting other documents,please state what you are attaching and how many pages:_____Attaching a proof of
reciept for having to purchase a new tire.Also,attaching a total of 6 pictures of the pothole and the damaged it did to my tire/
rim.____________________
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:__________________Sonny Yang______________________________
Signature of Person submitting this form:__________Sonny Yang________________________________
Relationship of person signing to Party making the claim:__________________________________________
Date document is being signed:___4/23/2023__________________
Revised March 2023