Gorham, MarilynNOTICE OF CIAIM FORM to the oty of saint Paul, Minnesota
Minnesato Stote Stotute 456.A5 stutesthot"...every peBan. .wha eloins donoqesfron ony nunicipolity. .shol cause to be ptesehted ta the Aavehing body afthe
nuni.ipalitywithin 130 ddys dftet the dlegetl lass ot injuty k.liscavercd a hatice stotihq the tine, pl,ce, ond.ncLnstonces therpof, ondrhe an.Lnt af comp"nsorbn
ot ather rc lieJ d.h dn ded "
peas.competerhslorm nitsEntirerybycl€aryrypingorprinringVouranswerstoeachqueston lyouhaleaddtiona docum€ntaron,yo!mayaddthose
documenrstoyoursubmkson. Youwi notbe.onradedbyt€leph.ne!ness.ariJication in.eded lhecaimproceslorlnvesu&tionscafiakeupwardrolfolria)
weeksThisformmustbesigned,datedwithalapprcabesectio.scompleled.submiss.nthkcomplet€dlormtothe.:'Li.r1:lj.iarriribyemai
(.irycerk@cr*paulmn ut, fax(651166 3574)orma addre$edio "saintP.u city crerk,15 w€sr Kell.gs Blld , sliL€ 31o, saint P3u , MN 55102-.
Claimant: First Name: Marilyn Last Name: Gorham
P e.se lndicate Yo!r PronoLrns: tr she/Her/Hers, tr HelBlm/His, !rhey/rhem/rhelrs
Company or Business Name:
s this .la m beinB made by an nsurance Company? NO lfyes,whatisyourCl.inrlFileNurnber? No-
s this clalm being made by an Attorney? NO lf yes, what is your F ie N!nrber?
lf yes, provide yo!r lnsured's/ Client's Name
state
Please che.kth€ reason that most clos€ly d€s.ribes the reason foryour submitting a claim. PIease note th€ documents that wil
reed ro be provided with your completed form. Photographs wil be accepted. All documents submitted become the propertY of
the clty of Saint Paul and shall not be returned.
please state why or howyou feeithe City ofSaint Paulls r€sponsible foryour Damages? The pothole was dangerous and should
have been filled long before drove through that intersection. lwasunabletogetbacktotheintersecuontotakeaphotoofthe
hole r.rntil May 28th at which time the pothole had been filled. Youcanseetheextentoftheareainvovedbasedonthesizeofthe
patching that was done. Numerous newspaper artlcles and television news stories have focused on the lack of pothole repair being
done rhis year bythe City ofSt. Pau andthepoorconditionoftheClty'sroadswhichwasres(]ltinglnnumerouscartbeinBdanrag€d
in multlple locat ons in the City.
DaYrime/Work Phone
Date of rncident or Datp Discovered (Must Comp ete):5/24/2023line: Approximately 2:00 p.m
n Automobile wastowed and mayor m.y not h.v€ sustained damage: please provide copy oftowingticket (lfavailable), rece pt
from lirpound Lot, and two estlmates for repairs or actua bil that has been paid.
D Snow Emergency: please provide copyoftowingticket (ifavailable), receiptfrom lmpound Lot, and two estimates for repairs or
actual billthat has been paid.
,df luilo
City:Zip Code:
Please state, in detail, \dhat happened that prompted yoLr to file a Notice oI C alm Formr My car tire was damaged beyond repalr by
a pothole at the intersection of I 35E & Rardolph Avenue. The pothole could not be avoided as turned east onto Rando ph from I
35E nol1hbo!nd. I drove up Lexingron Ave after hitting the potho e thinkifg there was no damage, however, by the t me I reached
Grafd and Avon, my tire was flat and had to c.1l a towing servlce to have the spare put on so I coLrld return to my home.
n Automobie damag€ from a motorvehicle ac.identiplease providetwo estimatesfor repairs or actual blllthat h.s beef paid
tr Automobile damage from a street defect or pothole: please provide two estimates for repairs or actLra bi i that has been pald.
D Property damage:please providetwo estimates for repajrs or actualbi that has been pajd.
E You were injured during a motorvehicle accident: please provide police report number, detaitsabout injury.
O You were injured in the CIty ofSaint Paul: please provide potice report number, witnesses, and details about injury
Continue to page 2 of t{otlce of Claim Eorm. Failurc to comptele and return both pages wifi resutt in detays.
Thls sectlon must becomoleted for all clalms.
ls there a pollce report forthis lncident? NO
lf yes, please providethe police r€port case number
lfyes, what law enfor€ement agency responded?
Where did the iocident take place? Please provide a street address, inrersection or name of city park or facitity
What would you llketo see happen to resolve this claim to your satisfaction?
tor oroD€rtv denBEe clalms. inaludinl vehlcle atcldents.
Your vehicle's inlormatio \eat 2022 Meke: VolkwaSen Model Passat Color: Red
Licens€ Plate#: ERRRXIE State vehlcle iS.eglstered iniwl
Registered owner ofvehicle: William and Marilyn Gorham
Driver: Marilyn Gorham
Area{s)damaged: Right rear tke was damaged beyond repair. Wheel cover was also damaged but reimbursement for that
is not being requested at thjs time. The total amount r€qu€rted for reimbursement is 5361.81. Paid invoic€s are attached.
lf a City vehicle was involved, License Plate f Color:
Was ther€ City insignia on the v€hicle? YES / NO Drive/s Name
Other property damaged
For iniurv claims ol anv tvoe.
What part of yolr bodywas anjured?
Did you go to the emergency room or urgent care? YES / No Where?
Was med ical treatment received? YES/NO Where?
First day of medical treatment?Are you stjll receiving medical treatment? YES / NO
,tyou are su bmittiG other documents, please state whatyou are attaching and how many pages: Total number of pages being
submittingincludingthisrorm s10. lncludeda.ethetirechangeinvoiceandthetirereplacementinvoicealonSwithphotosofthe
RevisedMarch2023
l0try-4
Were there witnesses to this inddent? Please provide names and contact phone numbers:
Did you miss any work as result of this in.ident? YES / NO
How mucn time have yod misseo trolr work?
tire change being done on by Elite Towing, the damaSe to th€ th€ and wheel cover and the pothole which was repaired afterthe
dama8e to fiy tir€ occurred,
ay siSnlng this torln, you a8ree that all lntormatlon pmvided ls true and co.red lo the best ot your knowledte.
Pl€ese I{OTE that asbmitting a t ls€ ot misleadlng clalm can and wlll result ln pros€cution under Mlnnesot. Statutes.
Name of Person completingform: Marilyn Gorham
Signatureof Pe.son submitting this form:
Relationship of person signingto Party making the c aimrSarne
Date document is being si|. ed:6123/2023
in"uq t0
RECEIPT
Basi. Details
calJ#
Date/Time
oate/lime
26596
25596
cash/Private Serail cusrorier
sl24/2AE @ 2t25 PM
V N Nrimber 1VWBArA!8Na009068
ModeL: 2022 Volkswagen Passat
L!.€nse Plar.:BRRRKtE (Wt)
D.ivab e: No
#26l:eB @ lJi+&Pr+
'/z+lzD"3 @ Z:d\t'M
Iire Chanse
(6s1-266-),
792Grund Ave,St Paul, MN 55105,
USA
tire chanBe
right rear
Charges Summary
units/Qry Price lineTotal
$gs.oo s95.00s0,00 so.oo
1
1
Subtotal 595.00
Taxes 50.00
Grand Total 595.00
Cash payment of S95.00 applied
Signature:
USDOT:3376675
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lnvoice #114113
Page 1 or2
0€l/30/m23
Ma lyn & Billcotham
+1 612-865-&569
2022 VollGvYagon Passal
1 WVBA7A3ANC009068
Engine:14,2.01i DOHC l6V;
PIAIC: BRRRKIE
odomeld 1ni25797
Odomete, Oulr25797
Advlsor:
Technician: Sam McNamee
GRAND TOTAL: $266.81
SERVICES
Galeway Aulo Care's 56 Polnt Digital lnspectign
inspecl lire for damage alt6r h lling a polhole
SUBTOTAL: $0.00
LAAOF
Digilal Courtesy lnspection For Sa!6ty And Reliability - Piclures included! Please reler to digilal
inspedion lor lesulF
Labor: S0.00
Pans: $0.00
Fees:90.00
Sublet: S0.00
Tire Replacement - 1 SUBIOTAL: S251.6a
Mountand comouter balance one tire
WHL WGTS & VLV STEM
235/45-18 GTTICOVFORT A1
SL TIRE
HAzMATS & FEES
Iire disposalfe6
$6.50
$209.14
$6.s0
$203.r 4
otY
1.0
FEE
$8.00 $8.00
Labor: $28.00
Pats:S215.64
F€os:38.00
sublet:s0.00
rl{btt l0
Gateway Auto Care lnc
715-386.8885
sBrvico@qalewayauloaare.corn
1.0
1.0
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Gateway Auto Care lnc
7r5 386,8885
iicrv'.e@9a:e,wayauioca.c Lr1lnr
lnvoice #114113
051302023
IYFS DO Ttlts !,OAI{.
I hereby asrho.ize rhe €resparrdin! 3epi.e Io b6 don. ala.q anh the .eressary oaraials.
2 'YOU I1I1AY DANE MY CAR ON PI,BLIC FOAOS'
GarsBay auto caE ln $all oay op€rare oy vehide lo. th€ plrpose or resrins, insp@lon,
3,'NO PAYMENT, NO KEYS'
Afoxpdgs ienls acknowledg€d on my vohrcl6 ro sec!rc fi6 aruunl or setuicas rherclo-
4, "ONLINE COMIIII]NICATION OK'
I {,€lcom€ email Jrofi OaEsay Aulo Care lir as ! means ol ,eceMnq copies ol my
os limate, work orde,, 2.d nvoice.
5, "HERE'S MY SIGNATURE"
I en&.se lhe anached digt€l imiqe ol hy sEnature as eqlrvateni ro my qirer srO&tur.
,rd 3s pr@l oi my ag.eemenl lo lheas lNe lerm.
GRAND TOTAL: $266.81
Total Labor: $28-00
Tolal Pa(s:S215.64
Total Fees: $a.00
Toral Sublers: $!-00
Shop Suppliesi $1.68
Sales Tax: $13.49
r/ PAID
Wananly penod ir 24 fronrhs or24,000 miles NATIONWIDE. Whi.hever @.!.s rtsr.
unlegs onetuise specili€d.
FOR ]ATIONWIDE WAFAANTY CLAIMS CALL ] .800452.6272
C5/30r2023 03 -8I't/]
eaid by cr€C rCerd v a Terr.air 5266.81
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