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Griffiths, Jill 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 _________________Sky___________ Last Name ____Griffiths___________________________________ 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? </w:t </w:t></w:r If yes, what is your Claim/File <Number?: _____________________ Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ </ Street Address: _________ 2078< St. Claire Avenue______________________________________ City: ___Saint Paul________________ State __MN____ Zip Code ___55105________ Daytime/Work Phone _____612-331-9090_______________ Cell Phone __612-800-2018__________________________________ Date of Incident or Date Discovered (Must complete) 1/12/2023Time _____ Evening of Jan 12 and morning of March 11, 2023____________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _On Thursday, Jan 12 on my way home from work my car hit a pothole in Saint Paul on No Eustis Street at a terrible stretch of road, not far from University Avenue. It really jarred my car. I was able to drive the short distance home but a dash light came on, so I knew I needed to check it. The tire was flat shortly thereafter. I had to borrow a parent’s car for work the next day. Saturday morning AAA towed my 2018 Prius to Discount Tire at 1350 University Ave, Saint Paul. One tire was not repairable. Jan 14 four new tires were purchased at a cost of $779.50. We also realized missing hubcap cover. No luck recovering. Invoice attached for that from Burnsville Toyota ($157.47 attached.)On the morning of March 11 I drove into a large pothole in Saint Paul on Cretin between Goodrich and Lincoln (nearest house address is 90 Cretin Ave So). The (new) front tire blew out and I was unable to move the car except to side of road near the intersection of Cretin & Goodrich. AAA was summoned. I waited a long time in the cold for the tow to arrive. It was again taken to Discount Tire. I was without a car for the weekend. They replaced a tire on the morning of March 13 for the insured amount of $23.28. I noticed a scraping sound underneath the car afterwards. The undersides of the car were hanging down. A mechanic helped me by bending a piece up underneath for a temporary fix (it still makes noise). March 17-21 two estimates were received for the repair to my Prius. Those are attached. I have also attached photos. I am driving without the adequate protective covers underneath my car (safeguards radiator and other parts), which is not advised. I have hopes of a quick repair once I receive monetary relief. Many shops are so busy now. I am eager to have this repair completed, but it is a financial hardship for me. Please state why or how you feel the City of Saint Paul is responsible for your Damages? _ I’ve never experienced such terrible road conditions. I am an extremely careful driver. I slow down and try to maneuver around potholes and patches of water where water collects in holes now that the snow is melting (disguises the hole). Sometimes it is just impossible to miss all the potholes! It is also dangerous to weave along the city streets as I and other drivers try avoiding the street damage. It has been very inconvenient for me and stressful this winter. I really hope the roads can be repaired soon. I have replaced five tires in two months time. And now I am dealing with additional repair costs (estimates attached). Toyota has also reminded me that my wheels are in need of alignment after these incidents (cost $160.94 attached.) - Absolutely I feel the City of Saint Paul is responsible. I would greatly appreciate some renumeration. Thank you so much for consideration! 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? Yes No If yes, please provide the police report case number ____________________ Revised December 2021 If yes, what law enforcement agency responded? _______________________________________________________ Where did the incident take place? Please provide a street address, intersection or name of City park or facility. The first incident on No Eustis Street in Saint Paul (I have sent a screen shot of a of the general area) and the second incident on Cretin Avenue in St Paul. I took a photo of two large holes plus the house in the background that identifies this place – 90 Cretin Ave South, Saint Paul. ________________________________________________________________________________________________________ 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? Payment toward my repairs as a result of these incidents due to damaged roads in Saint Paul_____________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers. _My mother and father separately came to help me the first time (Jill Griffiths 612-331-9090) and my father came the second time (Larry Pogemiller 612-770-0922), but I was alone driving when the incidents happened. For property damage claims, including vehicle accidents. Your vehicle’s information: Year 2018__ Make ____Toyota___ Model _____ Prius_______________ Color __White____________ License Plate # _____GXH886__________ State vehicle is registered in ______ Minnesota__________________ Registered owner of vehicle _ Sky Li Griffiths______ Driver ___ Sky Li Griffiths_________________________ Area(s) damaged ________________Front tires, rim, hubcap, underneath the car/all protective surfaces/coverings, bumper, connections, etc. Please see estimates for a more accurate list ___________________________________________________________________ If a City vehicle was involved: License Plate # _______________________________ Color _______________________________ Was there City insignia on the vehicle? Yes No Driver’s Name </w_____________________________________________ 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. ________ Sent estimates on repair and many photos. Initially sent a total 15 attachments including this form_____*** NOTE: Revised upon request to reduce content from City Clerk’s office on 3-27-23. Resubmitted with a total three attachments. One includes estimates, one includes a few photos, and then this Claim Form. 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: _____Sky Li Griffiths___________________________________________ < Signature of Person submitting this form: _______________________________________________________________________ Relationship of person signing to Party making the claim: ____self_______________ Date document is being signed 3/21/2023 Revised December 2021