Yang, GaoNOTICE 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 _Gao___________________________ Last Name __Yang_________________________________________
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? NO If yes, what is your Claim/File Number?: _____________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: 2535 Sylvan St_____________________________________________________________________________
City: __Little Canada____________ State ____MN__________ Zip Code ___55117______
Daytime/Work Phone __651-270-4694___________________ Cell Phone __651-270-4694____________________
Date of Incident or Date Discovered (Must complete) 2/28/2023Time ____9:30am_____________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Front passenger tire and wheel damaged
from running over multiple potholes that were unavoidable due to the number of holes in close proximity of each other across the
entire road on 7th Street West between the river and 35E.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __City did not patch or fix road, road had
multiple potholes in close proximity of each other in multiple areas 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.
☒ 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 ____________________
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.
Driving northeast on 7th Street West between W. Maynard Drive and E. Maynard Drive________________
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? I am asking for either: a) reimbursement to replace at
least 1 Tire with warranty for $94.21, and 1 Wheel for $156, plus tax of $13.49, for a total of $263.70; or b) reimbursement for the
full amount of my bill attached which is $986.29 since I had to replace the other 3 tires in addition to the 1 damaged tire and wheel
because my car is all wheel drive and is recommended by the manufacturer to have even tread.
Were there witnesses to this incident? Please provide names and contact phone numbers. _No_____________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2009__ Make _Subaru___ Model ___Impreza 2.5 GT_________ Color _Silver______________
License Plate # __BYC 267___________________ State vehicle is registered in __Minnesota______________________
Registered owner of vehicle _Gao Lee Yang__________________ Driver _Baonhia Xiong_________________
Area(s) damaged ___Front Passenger side wheel and tire_________________
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. ______________________
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: ___Gao Lee Yang_____________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 4/4/2023
Revised December 2021