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Milton, Joseph 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 ____Joseph________________________ Last Name ____________________________Milton_________________ 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? If yes, what is your Claim/File Number?: ________________No_____ Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________No________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ </ Street Address: 1879 Chelton Ave West #2_________________________________________________________________________________________ City: _____________St Paul_______________________________ State __________MN_________ Zip Code _____55104_____________ Daytime/Work Phone ____________________612-398-1184___________ Cell Phone ____________________________________________ Date of Incident or Date Discovered (Must complete) ____________________3/14/2023@ 10:10am_________Time _________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. We were traveling down Fairview going south towards the 94 bridge under pass& hit a humungous pothole that has now damaged the the passenger front tire& possibly the brake rotor or tire rod. We are expericing a rubbing noise of metal clicking& clacking when the car is in motion. _____________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? _________It almost seems impossible that the City wouldn'thave known about this because the pothole is so big& deep that the front end of our car went down in the hole of the road 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. Alutomobile 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? Yes No If yes, please provide the police report case number _____________NO_______ Revised December 2021 If yes, what law enforcement agency responded? __________________________________________NO_____________ Where did the incident take place? Please provide a street address, intersection or name of City park or facility. FAIRVIEW & 94 BRIDGE UNDERPASS ST PAUL MN ________________________________________________________________________________________________________ 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? ______________________PAY FOR THE DAMAGES TO OUR VEHICLE& FIX THE HOLE IN TH ROAD ASAP___________________ Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year _2003__ Make __________ES300_______ Model ________LEXUS____________ Color __SILVER______________ License Plate # _________JTR792____________ State vehicle is registered in ______MN__________________ Registered owner of vehicle ____________________JOSEPH MILTON__________ Driver ______________________________________ Area(s) damaged ___________________________FRONT PASSENGER TIRE&OTHER DAMAGES UNKNOWNAT THIS TIME UNTIL ESTIMATE CAN BE COMPLETED________________________________________________________ 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 still receiving medical treatment? Yes No Did you miss any work as result of this incident? Yes No Employer(s) _______________________________________________ How much time have you missed from work?___________________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages. ______________1 ATTACHMENT OF BULGE IN FRONT PASSENGER TIRE________ 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: ______________JOSEPH MILTON__________________________________ Signature of Person submitting this form: _______Joseph Milton __________________________________________Joseph Milton_____________________ Relationship of person signing to Party making the claim: ___________________ Date document is being signed ____3/14/2023_________ Revised December 2021