Khang, Choua
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
after the alleged loss or injury is discovered a notice stating the time, place, and circumstances thereof, and the amount of compensation or other relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question. If you have additional documentation you may add those documents to your submission.
You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks. This form must be signed, dated with
all applicable sections completed. Submission is to the Saint Paul
https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may <
mailto:cityclerk@ci.stpaul.mn.usemail, 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 Choua Last Name Khang
Please Indicate Your Pronouns: She/ Her/Hers ☒ He/Him/His <☐_ They/ Them/Theirs ☐
Company or Business Name: N/A
Is this claim being made by an Insurance Company? N/A If yes, what is your Claim/File <Number?: N/A
Is this claim being made by an Attorney? NO If yes, what is your File Number? N/A
If yes, then provide your Insured’s/ Client’s Name _______________N/A_____________________________________________
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Street Address: 1862 Margaret Street
City: Saint Paul State Minnesota Zip Code 55119
Daytime/Work Phone 651-242-0005 Cell Phone 651-242-0005_
Date of Incident or Date Discovered (Must complete) 02//14/2023Time 6:30pm to 7:00pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Hit a pothole while driving west bound on Minnehaha Ave E. It was raining and couldn’t see
the pothole.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Both the wheels on the right passenger side are damage due to the pothole. __________________
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.
☒ 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.
This section must be completed for all claims.
Is there a police report for this incident? NO If yes, please provide the police report case number ________N/A____________
Revised December 2021
If yes, what law enforcement agency responded? N/A
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
The incident take place at Minnehaha Ave E and Clarence. Near to the house 1323 Minnehaha Ave E.
Notice 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 satisfaction? Replace the damage on the passenger side wheel and rear side wheel. So, I can feel safe driving around with
my family 2 child.
Were there witnesses to this incident? Please provide names and contact phone numbers. My wife, Qao Shoua Xiong 651-242-0005
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2016 Make Toyota Model Camry Color White
License Plate # HHN 872 State vehicle is registered in Minnesota
Registered owner of vehicle Qao Shoua Xiong______________________________ Driver Choua Khang
Area(s) damaged Both wheels are damage, and they are locate at right passenger side and right rear
If a City vehicle was involved: License Plate # N/A_ Color N/A
Was there City insignia on the vehicle? NO Driver’s Name </wN/A
Other property damaged: N/A
For injury claims of any type.
What part of your body was injured? N/A
Did you go to the emergency room or urgent care? NO Where? N/A
Was medical treatment received? NO Where? </N/A
First day of medical treatment? ______N/A_______ Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? NO Employer(s) <N/A
How much time have you missed from work?__N/A
If you are submitting other documents, please state what you are attaching and how many pages. 5
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: Choua Khang <
Signature of Person submitting this form: Choua Khang
Relationship of person signing to Party making the claim: SELF
Date document is being signed 2/15/2023
Revised December 2021