Vang, ChongNOTICE 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 _____Chong_______________________ Last Name _________Vang____________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His X☐_ 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 AKorney? NO If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: __1773 Van Buren Ave____________________________________________________________________
City: _____St. Paul ______________________________ State _______MN__________ Zip Code ______55104____________
DayWme/Work Phone _______________________________ Cell Phone ______6517073270______________________________
Date of Incident or Date Discovered (Must complete) ______4/16/23___________________Time ______8:30am_______________
Please state, in detail, what happened that prompted you to file a NoWce of Claim Form. _______I was driving westbound on
Charles Ave from Snelling Ave and hit a pot hole because there are mulWple pot holes on that street.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _The city of St. Paul is responsible for
damages as my flat Wre was due strictly to the condiWon of the road. The potholes are so severe that they are completely
unavoidable. _____________________________
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 submiKed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esWmates for repairs or actual bill that has been paid.
X Automobile damage from a street defect or pothole : please provide two esWmates 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 Wcket (if available), receipt
from Impound Lot, and two esWmates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing Wcket (if available), receipt from Impound Lot, and two esWmates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two esWmates 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? 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, intersecWon or name of City park or facility.
_____It took place on Charles Ave and west of Snelling Ave.
_________________________________________________________________________________________________
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 saWsfacWon? ___My bill for replacing my car Wre to be paid. _____
Were there witnesses to this incident? Please provide names and contact phone numbers. I was driving alone home from work, so
no.
For property damage claims, including vehicle accidents.
Your vehicle’s informaWon: Year _2023___ Make ___Nissan______________ Model ___AlWma_________ Color ___Grey_____
License Plate # ________JDU741_____________ State vehicle is registered in ___MN_____________
Registered owner of vehicle __Chong Vang_____________________ Driver____Chong Vang_____________________
Area(s) damaged ____Leh Front Side Tire__________________________________________________
If a City vehicle was involved: License Plate # _______________________________ Color ___________________________
Was there City insignia on the vehicle? Yes No Driver’s Name _Chong Vang__________________________________
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 sWll receiving medical treatment? Yes No
Did you miss any work as result of this incident? Yes No Employer(s) _______________________________________________
How much Wme have you missed from work?___________________________________________________________________
If you are submi_ng other documents, please state what you are aaaching and how many pages. ___Photos of the potholes and
bill for Wre replacement. ___________________
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 compleWng form: __Chong Vang _____________________________________
Signature of Person submiing this form: ____________________
RelaWonship of person signing to Party making the claim: ________________Self ___
Date document is being signed __4/4/23___________
Revised December 2021