Vu, Stephan
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 this completed form to the
mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint Paul City Clerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West
Kellogg Blvd., Suite 310, Saint Paul, MN 55102”.
Claimant: First Name: Stephan Vu Last Name: Vu
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, provide your Insured’s/ Client’s Name: N/A
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Street Address: 1601 70th Ave N
City: Brooklyn Center State: MN Zip Code: 55430
Daytime/Work Phone: N/A Cell Phone: 763.218.9857_
Date of Incident or Date Discovered (Must Complete): 3/17/2023 Time: 3:00pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I was driving in St. Paul on Cretin Ave S, near the University of St. Thomas, and there was a
very deep pothole on the right side of my lane. I could not avoid it due to traffic coming from the other side of the street and was forced to hit the pothole. I got a flat tire after
that. My car was towed to a mechanic shop, Steve’s Tire and Auto, and they replaced my flat winter tire with one of my spare summer tires. The mechanic did find a significant dent in
the rim and informed me to get it straitened out otherwise it’ll cause further complications. I then took my the bent rim to Alloy Wheel Repair in Shoreview and they fixed the bent rim.
I had to pay $38.48 to get my tires changed at Steve’s Tire and Auto and $126 to fix the bent rim at Alloy Wheel Repair, with the total coming to $164.48.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The pothole was in Saint Paul and it was impossible to drive around it with the on coming traffic
from the other side. The city did not fill the pothole or block it off, leading me to drive into it with no warning of it being there and no way of avoiding it.
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.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
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: ___________________________
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:
Cretin Ave S somewhere between Summit Ave and Fairmount Ave
What would you like to see happen to resolve this claim to your satisfaction? I would like to be reimbursed for the $164.48 repairs that had to be done, and for the potholes to be filled.____________________________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 No
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2019 Make: Honda Model: Civic Si Color: White
License Plate #: CHM 371 State vehicle is registered in: Minnesota
Registered owner of vehicle: Stephan Vu Driver: Stephan Vu
Area(s) damaged: Wheel on the front passenger side
If a City vehicle was involved, License Plate #: N/A _ Color: _______________________________
Was there City insignia on the vehicle? YES / NO Driver’s Name</w: ______________________________________________________
Other property damaged: None
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? ___________________________________________________
Was medical treatment received? NO Where? </________________________________________________________________
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): _________________________________________________________________________________________________
How much time have you missed from work? _____________________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: Submitting two pictures of the receipt for the two repairs done on the wheel that hit
the pothole.
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: Stephan Vu <
Signature of Person submitting this form: Stephan Vu
Relationship of person signing to Party making the claim: Self
Date document is being signed: 4/14/2023
Revised March 2023