Yang, MeeNOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that # ... every person ... who claims damages from any mun/clpallty .. .sho// cause to be presented to the governing body of the
municipa6ty within 180days after the alleged loss or injury is discovered a notice stating the time, place, and drcumstances thereat and the amount of compensation or ather ;efief demanded.•
Please complete ti-is form In Its entirety by clearly typing or printing your answers to each question. If you halll! additional documentation you may add those
documents to your submission. You wll not be contacted by telephone unless clarification Is needed. lhe cl aim process for Investigations can take upwards of
four (41 weeks. lhlsform must beslgned,dated with all applicable sections completed. Submission Is to the Saint Paul City Clerk's Office. You may emall, fax
(651-266-8574) or mail the form. Mailing address Is "Saint Paul City Clerk, 15 West Kellog Blvd., Suite 310, Saint Paul, MN 55102"
Individuals: First Name Jl}1..QJL, Last Name ....... ~4+-~~~i't--------------
Please Indicate Your Pronouns: She/ Her/Hers 1?J He/Him/His D_ They/ Them/Theirs D
Company or Business Name:----------------------------------
Is this claim being made by an Insurance Company? 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 Insure d's/ Client's Name
Street Address:---------------------------------------
City: ___________________ State ________ Zip Code _______ _
Daytime/Work Phone ______________ Cell Phone __________________ _
Date of Incident or Date Discovered (Must complete) Lj \ -?-o ;>-_?z'--__ nme --a..l \_~_'3_0 __ 'f~""'-----
P1ease state, in detail, what happened that prompted you to file a Notice of Claim Form. l:h+-C,.... pot" ~l-t.s
IM~ W ~\ f/'W\.&. \:)\-u.\) -~ ,t\('.J.;
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ...,Tu~r...-.--1P,--± ....... hv.=...:\ .... ::1_$.-_fs......,_~j_,f+_. of ~'-I !-J
l-4~ .
Please check the reason that most dosely desaibes the reason for your submitting a daim. Please note the documents that will C\ •
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. l nltt~t. 4,4)
Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
R Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid.
D 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.
D 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.
D Property damage: please provide two estimates for repairs or actual bill that has been paid.
0 You were injured during a motor vehicle accident: please provide police report number, details about injury.
D 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.
s+v~
Notice of Calm Form, page two. Failure to complete and return both pages wlll result In delays.
What would you like to see happen to resolve this claim to your satisfaction? t' <.\"'--\.,~"-It, -Pr, r-AA\M..A-"z/2.-:
Were there witnesses to this incident? Please provide names and contact phone numbers. ____________ _
For property damage dalms, lndudlng vehlde accidents.
Your vehicle's information: Year~ Make -~--~~----Model Ac..'-d <'J.._ Color wk~
License Plate # _________ State vehicle is registered In __ YV\I\J ________ _
Registered owner of vehicle __ v-v.__~"'"'· =---~~•-':..;..:;~f----Driver __ lAA-'---~--="---$=-tt-"".a.¥'--::ZT:;.-F--------
Area(s) damaged rv..ktl .Cv-UV'\.f 4,J:b.-0,..,\ ' 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 JnJury daJms of any twe,
What part of your body was injured? ----~"'-A....,_ _________________________ _
Did you go to the emergency room or urgent care? Yes No Where? __ __.,Jrw,,,e_,_f\:~----------------
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? ____ """"-''--"--'------------------------
lf you are submitting other documents, please state what you are attaching and how many pages. 3 pk & +o ).. <-rl-,~
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 wl/1 result in prosecution under Minnesota Statutes.
Name of Person completing form: ~~-~O~V\_AA~"'/ __ y\ __ [,\V'fu ___________ _ 6
Signature of Person submitting this form: --'~"----e----------------------------
Relationship of person signing to Party making the claim: h,~
Date document is being signed -/ O ,.. 7.))
Revised December 2021
04-08-2023 5:03 PM DISCOUNT TIRE PRICE QUOTE
CUSTOMER INFORMATION
MONEY N YANG
3244 GREENBRIAR ST
VANNAIS HEIGHT MN 55127
(H) 651-387-7595
CODE CC QTY SIZE/DESCRIPTION
50339 NRM 1 18 x0 .5 5-114.30
TSW SEBRING
40
VEHICLE INFORMATION
2015 HONDA
ACCORD SEDAN
18"BASE SPORT
PLATE# UNKNOWN
MILEAGE: UNKNOWN
TORQUE SPECS: 080
BKMTXX
76.10
WARRANTY: LIFETIME STRUCTURAL AND 1 YEAR FINISH
COMMENT: BOLT PATTERN: 5-114.3
40874 NRM 1 235 /45 Rl8 94H SL BSW
BRI BLIZZAK WS90
WARRANTY: WORKMANSHIP/MATERIALS-LIFETIME
COMMENT: INFLATION F:33 R:32
80219 NRM 1 INSTALLATION &
LIFE OF TIRE MAINTENANCE
FREE CUSTOMER FLAT REPAIR AND ROTATION -
This quote is good for 30 days
THANK YOU FOR SHOPPING DISCOUNT TIRE CO.
QUOTE#
STORE LOCATION
MNM 14
PAGE
60932
1
13341 60TH ST N
STILLWATER MN 55082-1287
PHONE: 651-351-5172
099 MICHAEL J M
F.E.T. PRICE
.00 255 .00
.00 192.98
.00 22 .00
TAX:
TOTAL:
AMOUNT
255.00
192.98
22 .00
33.04
503.02
(Salesman's Signature)