Xiong, Yee
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: Yee</ ________________________________ Last Name: Xiong< _______________________________________________
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? YES / NO If yes, what is your Claim/File Number? <No_________________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? No_______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
</
Street Address: 1612 Stillwater Ave. Click or tap here to enter text.
City:Saint Paul ______________________________________________ State: MN________________________ Zip Code:55106 ___________________
Daytime/Work Phone: __________________________________ Cell Phone:651-403-0056 _____________________________________________
Date of Incident or Date Discovered (Must Complete): May 10, 2023 _____________________________ Time: 9:10 AM _____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: Their a big pot hole in the middle of the road and I road over it and it pop my tires ____________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? This pothole has been there for a long time now. And it so big that you can plant a tree in 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? YES / NO
If yes, please provide the police report case number: No___________________________
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:
Battle Creek Regional Park at Burns Ave. ____________________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? Click or tap here to enter text.I need my refund on tire repair and need that pothole fixed. ____________________________________________________________________________________________________________
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 ____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2010_________ Make: Acura _________________ Model: TSX__________________ Color: Black__________________
License Plate #: JDG 928_________________________ State vehicle is registered in: Minnesota ___________________________
Registered owner of vehicle: Yee Xiong _____________________________ Driver: Yee Xiong __________________________________________
Area(s) damaged:Driver side tires______________________________________________________________________________________
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: 3 pictures of proof_________________________
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: Yee Xiong_____________________________________________________________ <
Signature of Person submitting this form: Yee Xiong_______________________________________________________
Relationship of person signing to Party making the claim: self__________________________________________
Date document is being signed: May 11, 2023_____________________
Revised March 2023