Lozada, John RoyNOTICE 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 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 ___________John Roy ______ Last Name ________________Lozada_____________________________
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? NO 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________________________________________________
Street Address: _____________3020 University Ave SE, Apt 206_______________________________________________
City: _______________Minneapolis_________________ State __________MN_________ Zip Code _______55414___________
Daytime/Work Phone _________201-289-7933___________ Cell Phone ______201-289-7933____________________
Date of Incident or Date Discovered (Must complete) 3/5/2023Time ___________11am______________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was driving on N Eustis St in between
University and Franklin Ave and encountered multiple major potholes. My indicator sensors for tire pressure turned on
shortly after going over the potholes, leading me to have to change the front left tire to a spare as it was immediately
unusable. Upon bringing my vehicle to the tire repair shop, the other two tires were also deemed unusable due to pothole
damage. Thus 3 total tire replacements needed to be done due to pothole damage.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Haven’t fixed the pothole. Has been there
for several months now.
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.
____________N Eustis Street in between University Ave SE and Franklin Ave______________________
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? _Reimbursement/compensation for tire replacements
Were there witnesses to this incident? Please provide names and contact phone numbers. _______N/A_______________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year __2021____ Make _____Mazda____ Model _______Mazda3_____ Color _______Grey_________
License Plate # ________J54NCX_____________ State vehicle is registered in _____NJ___________________
Registered owner of vehicle ____Reynaldo Lozada_________ Driver _____John Roy Lozada________________
Area(s) damaged _________Tires______________________________________________________
If a City vehicle was involved: License Plate # ____________NA___________________ Color _________NA____________________
Was there City insignia on the vehicle? Yes No Driver’s Name _________NA____________________________________
Other property damaged: ______________________NA_____________________________________________________________
For injury claims of any type.
What part of your body was injured? ___________NA_______________________________________________________________
Did you go to the emergency room or urgent care? Yes No Where? __________NA_______________________________________
Was medical treatment received? Yes No Where? ___________________NA___________________________________________
First day of medical treatment? ______NA_______ Are you still receiving medical treatment? Yes No
Did you miss any work as result of this incident? Yes No Employer(s) _____NA__________________________________________
How much time have you missed from work?________________NA___________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages. ___________2___________
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: __John Roy Lozada______________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/6/2023
Revised December 2021
275938
FINAL INVOICE
Out: 03/06/23 05:02PM
In: 03/06/23 09:09AM
Retail Invoice Store# 026239
www.FirestoneCompleteAutoCare.com
Cust Status: Drop Off Appt: Yes
Emailed on 03/06/2023
Emailed to roylozada99@gmail.com
FORD PARKWAY - 2269 FORD PKWY, SAINT PAUL, MN. 55116-1817 - 651.690.5123
3020 UNIVERSITY AVE SE
201.289.7933
MINNEAPOLIS, MN 55414-3740
2021 MAZDA 3 SELECT
2.5L L4 FI GAS VIN M DOHC
LIC #: J54NCX NJ
MILEAGE: 17,004
Service Advisor: 69 WOLTERS Wheel Lock:
Customer Details:Vehicle Details:
LOZADA, JOHN
Alt. Auth. Name & Phone:
N/A
Technician: 99 GARETT
VIN #: 3MZBPBBMXMM207916
Unit Extended JobRev Hist
Description Qty Price Price TotalID/Article #
COURTESY CHECK 69
CHECK LEFT FRONT TIRE
7046930 99NS N/CN/CCOURTESY CHECK 1
BRIDGESTONE TIRE PACKAGE 655.50691
012765 99TN 572.97190.99012765MX01 POTENZA RE980AS+ BL 215/45R18 XL93W 50,000
Mile Limited Warranty
3
DOT# 1RB4MR9815022
DOT# 1RB4MR9815022
DOT# 1RB4MR9815022
7013632 99NS 38.9712.99NEW TIRE WHEEL BALANCE LABOR 3
7008190 99NS 9.003.00TPMS VALVE SERVICE KIT LABOR 3
7014674 99TN 22.477.496-213 6-213 TPMS REPLACEMENT VALVE 3
7075078 99TN 12.094.03SCRAP TIRE RECYCLING FEE 3
7006472 99NS N/CN/CLOW PROFILE TIRE INSTALLATION 3
FREE ALIGNMENT CHECK - TIRE QUOTE OR W/ TIRE PURCH 692
7009886 99NN N/CN/CFREE WHEEL ALIGNMENT CHECK - ONLINE QUOT 1
ORDER NOTES
No manufacturer's recommended services were found.
none.
On Line Customer requested work: Tire Replacement
All parts are new unless otherwise specified.
Payment History:
Discover 00687R Sale6277 707.19
MID: 222220327556
Term: 0002 Card Inserted
PIN NOT VERIFIEDAID:A0000001523010
Total Tendered 707.19
$707.19Total
47.85Tax (7.875%)
659.34Sub-Total
3.84Shop Supplies
Labor 60.06
Parts 595.44
Summary:
Revision History:Amt
Rev
03/06/2023 10:19AM LOZADA, JOHN 201.289.7933816.261)
03/06/2023 02:07PM LOZADA, JOHN 201.289.7933-109.072)
I acknowledge notice and oral approval of
a change in the original estimated price.
Signature or Initials
Declined Work:
BRIDGESTONE TIRE PACKAGE
Inv1_WP 12.09.2020.102Page 1 of 2
Information on service warranty, maintenance, and safety can be located at
https://www.firestonecompleteautocare.com/maintain/service-warranty-options/
275938
FINAL INVOICE
Out: 03/06/23 05:02PM
In: 03/06/23 09:09AM
Retail Invoice Store# 026239
www.FirestoneCompleteAutoCare.com
Cust Status: Drop Off Appt: Yes
Emailed on 03/06/2023
Emailed to roylozada99@gmail.com
FORD PARKWAY - 2269 FORD PKWY, SAINT PAUL, MN. 55116-1817 - 651.690.5123
ALIGNMENT SERVICE
Information on tire warranty, maintenance, and safety can be located at
https://www.firestonecompleteautocare.com/tires/warranty-options/
or by calling toll free 800-847-3272 to obtain a free printed copy
I have received the above goods and/or services. If this is a
credit card purchase, I agree to pay and comply with my
cardholder agreement with the issuer.
Customer Signature
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Inv1_WP 12.09.2020.102Page 2 of 2
Information on service warranty, maintenance, and safety can be located at
https://www.firestonecompleteautocare.com/maintain/service-warranty-options/