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Scan2022-04-08_121845_000 NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota Minnesota StateStatute466.05states that"...every person.,.who ctaimsdamogesfrom any municipality.,.shall cause to�be presented tothe governing bodyof the municipali ry within 180 days after the alleged loss or injuryis discavered a notice stating the time,place,and circumstan ces thernof,a nd the amount of compe nsation or other relief demanded." please complete thisform in its entirety 6y clearlytyping or printingyour answersto each qu estion. If you have additional daumerrtation you mayadd those documentstoyoursubmission.Youwill notbe corrtacted bytelephone unlessclarification isneeded.The claim processtor investigationscantake upwardsof four{4)weeks. Thisform must besigned,dated with all applicable sectionscompleted. Submission isto the 5aintPaul C,,,i,� lerk's ffice. You maygmail,fax (651-266-8574)ormailtheforrn. Mailingaddressis"SaintPaulCityClerk,lSWestKelloggBlvd.,Suite310,SaintPaul,MN 55102" Individuals: First Name __�G�l _____�___�_LastName _Y_Y_G�- ________________--_— — —� Please Indicate Your Pronouns: She/Her/Hers I�He/Him/His ❑_They/Them/Theirs ❑ � Company or Business Name:--------------------------------------------------- Is this claim being made by an Insurance Company? �� If yes,what is your Claim/File Number?: _______,__ _ Is this claim being made by an Attorney? ��t��e�t1 iteC1't,If yes,what is your File Number? ___________________.—_ If yes,then provide your Insured's/Clien�s Name ___���_�="!��' ____—_—_—_ _-------- � Street Address:__����_�'��—��--��------------ -------------- City: _�—�(���GiU.�,---- -- —_State__I��'�1— ---- Zip Code_�����--- Daytime/Work Phone_ ______________--Cell Phone________ ___ Date of Incident or pate Discovered (Must complete)_�������_______Time__��S,�_�1/�_ _ Please sfate, in detail,what happened that prompted you to file a Notice of Claim Farm, I was coming home from work on I-694 exiting to Exit 52Ato North Saint Paul, while I was about to merge to 361 ran over a pothole that was covered in water.At the instant.my passenger back tirefelt like it blew out. My carslid a bit and I got a warning that my right-side passenger back tire has zero air in it the tire. So,1 exit off Hadley Ave N to the fleet Farm gas station to check my tire and it was flat. The pothale had punctured a big hole into the tire. �, Please state why or how you feel the City of Saint Paul is responsible for your Damages? These potholes need to be filled as soon as possible to preventfurther damages or even car accidentto other drivers. I have taking that exit many times and has never h ad this problem before.If the pothole was patched my truck tire would've not been punctured by the pothole. I could've gotten into a car accident as welL Please check the reason that most clasely describes the reason for yaur submitting a claim. Please note the documents that will needto be provided with your campleted form. Photographs will be accepted. Ail documents submitted become the propertyof the City of Saint Paul and shall not be returned. [�Automobile damage from a motor vehicle accident: please pravidetwo estimates far repairsor actual bill that has been paid. ❑ Automobile damage from a street defect or pothole :please provide two estimates for repairs or actual bill that has been pai d. ❑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}, receiptfrom Impound Lot,and two estimates for repairs or actual bill that has been paid. ❑ Property damage; please provide two estimates for repairs ar actual bill that has been paid. ' ❑You were injured during a motor vehicle aecident: please provide police report number,details about inju'ry. � ❑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.