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Yang, Thao Keng 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 aer the alleged loss or injury is discovered a noce stang the me, place, and circumstances thereof, and the amount of compensaon or other relief demanded.” Please complete this form in its enrety by clearly typing or prinng your answers to each queson. If you have addional documentaon, you may add those documents to your submission. You will not be contacted by telephone unless clarificaon is needed. The claim process for invesgaons can take upwards of four (4) weeks. This form must be signed, dated with all applicable secons completed. Submission this completed form to the Saint 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: ________________________________ Last Name: _______________________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs Company or Business Name: ____________________________________________________________________________________ Is this claim being made by an Insurance Company? YES / NO If yes, what is your Claim/File Number? _________________________ Is this claim being made by an Aorney? YES / NO If yes, what is your File Number? _______________________________________ If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________ Street Address: _______________________________________________________________________________________________ City: ______________________________________________ State: ________________________ Zip Code: ___________________ Dayme/Work Phone: __________________________________ Cell Phone: _____________________________________________ Date of Incident or Date Discovered (Must Complete): _____________________________ Time: _____________________________ Please state, in detail, what happened that prompted you to file a Noce of Claim Form: ____________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____________________________________ Please check the reason that most closely describes the reason for your subming a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submied become the property of the City of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: please provide two esmates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole: please provide two esmates 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 cket (if available), receipt from Impound Lot, and two esmates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing cket (if available), receipt from Impound Lot, and two esmates for repairs or actual bill that has been paid. ☐ Property damage: please provide two esmates 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. Connue to page 2 of Noce of Claim Form. Failure to complete and return both pages will result in delays. Revised March 2023 THAO KENG YANG 12/20/24 Between 1am - 7am City worker left note how to file claim City worker vehicle hit and broke my vehicle driver side mirror 920-629-8582 This secon 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: ___________________________ If yes, what law enforcement agency responded? ____________________________________________________________ Where did the incident take place? Please provide a street address, intersecon or name of city park or facility: ____________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your sasfacon? ____________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: ____________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s informaon: Year: _________ Make: _________________ Model: __________________ Color: __________________ License Plate #: _________________________ State vehicle is registered in: ___________________________ Registered owner of vehicle: _____________________________ Driver: __________________________________________ Area(s) damaged:______________________________________________________________________________________ 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 sll receiving medical treatment? YES / NO Did you miss any work as result of this incident? YES / NO Employer(s): _________________________________________________________________________________________________ How much me have you missed from work? _____________________________________________________________________ If you are subming other documents, please state what you are aaching and how many pages: _________________________ By signing this form, you agree that all informaon provided is true and correct to the best of your knowledge. Please NOTE that subming a false or misleading claim can and will result in prosecuon under Minnesota Statutes. Name of Person compleng form: _____________________________________________________________ Signature of Person subming this form: _______________________________________________________ Relaonship of person signing to Party making the claim: __________________________________________ Date document is being signed: _____________________ Revised March 2023 24 - 235 - 063 St. Paul Police Department Vehicle was parked on Ross Ave E. near corner of 7th st. E and Ross Ave in St.Paul Pay the cost of repair, which is $284.55 Street Maintenance worker Alex D. Saete called the police and made the report 2010 Toyota Rav4 Silver AVS - 4902 Wisconsin Thao Keng Yang Thao Keng Yang Front Driver side mirror 976967 Alex D. Saete None N/A 4 page: police report card, City driver report card, Receipt paid cost of repair, Photo of damage Thao Keng Yang Self 12/27/24