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Lee, Meyayua 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 ___________Meyayua___________ Last Name ______________Lee_______________________ 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?: <_____________________ 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: __1682 Euclid Street________________________________________________________________________ City: _____________Saint Paul______________________ State ____MN_____________ Zip Code ______55106________ Daytime/Work Phone _____651-313-0062_________________ Cell Phone ____________651-313-0062________________ Date of Incident or Date Discovered (Must complete) 4/3/2023Time ___6:49 PM_______________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _I was driving on Larpenteur Ave heading home from work and as I drove pass the intersection of Larpenteur Ave and Jackson St, I drove over a large pothole that took up the whole right lane. The tire on the front right side popped right after I drove over this pothole. It was hard to avoid as it took up the whole driving lane. ______ Please state why or how you feel the City of Saint Paul is responsible for your Damages? _I feel that the city is responsible for my tire being popped because they oversee fixing the roads making sure drivers can drive safely to their designated location. The pothole I hit was huge so I’m curious how long it has been there. I feel that potholes this large should be a priority to patch and should not be ignored or prolonged to patch. It is dangerous and may cause car accidents especially since Larpenteur Ave is a main road in Saint Paul. _______ 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. _The incident took place on the right lane of the road at the intersection of Jackson Street and Larpenteur 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? _I would like to see the potholes on the intersection of Jackson Street and Larpenteur Ave to be patched and a reimbursement for my tire damage._______ 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 __2020_ Make __Toyota______ Model ____Camry________ Color ____Black________ License Plate # ___ETT569___________ State vehicle is registered in _Minnesota_____________ Registered owner of vehicle ______Meyayua Lee__________ Driver __________Meyayua Lee___________________ Area(s) damaged __________Front right tire____________________________________________________ If a City vehicle was involved: License Plate # _____N/A_________________ Color _________N/A______________________ Was there City insignia on the vehicle? NO Driver’s Name </w____________N/A______________________________ Other property damaged: _________N/A_______________________________________________________________________ For injury claims of any type. What part of your body was injured? ____________________None___________________________________________________ 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? Yes 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. _Image of tire damage, image of pothole, estimate of tire repair (1 page), paid bill for new tires. ____________ 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: __________Meyayua Lee___________________________ < Signature of Person submitting this form: _________Meyayua Lee____________________________________________________ Relationship of person signing to Party making the claim: SELF Date document is being signed 4/4/2023 Revised December 2021