Yoshida, GeorgeI NOTICE OF OAIM FORM to the aty of Saint Paul, Minnesota
Mi~~esota State Statute 466.05 stotes thot ". .. every person ... who claims damages from any mun/clpallty .. .sha/1 cause to be presented to the governing body a/ the
mumcipa//ty 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 dearly typing or printing your answers to each question. If you have add"ttlonal documentation, you may add those
documents to your submission. You will not be contacted by telephone unless dartftcatlon 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. Submlss"ron this completed form to the Saint Paul City Clerk's Office by email
(cltyclerk@ci.stpaul.mn.us), fax (651-266-a574) or mall addressed to "Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102".
Claimant: First Name: George Last Name: Yoshida -----------
Please Indicate Your Pronouns: □ She/Her/Hers, 181 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 daim being made by an Attorney? YES/ NO If yes, what is your File Number? __ No ____________ _
If yes, provide your lnsured's/ Client's Name: ------------------------------
Street Address: _7729 N Wilkie Rd ------------------------------
City: _Hayward ________________ State: WI Zip Code: 54843
Daytime/Work Phone: ______________ Cell Phone: 612-5~564 ____________ _
Date of Incident or Date Discovered (Must Complete): S/10/2023 Time: _10:00 PM _________ _
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I was traveling south on 35E then took the
St.Clair exit where I encountered multiple potholes. The exit ramp turns into Pleasant Ave. The potholes were exactly at the
intersection of the exit ramp/Pleasant Ave and St. Albans St. There were at least three cars damaged in addition to mine that
required repairs to flat tires. I have induded two of the other vehicle owner's names and phone numbers. Trooper James Lee #656
from the Minnesota State Patrol arrived on the scene to assist with the incident. The first thing he did was make sure we were all
safe and then he placed a traffic cone in front of the potholes so no more cars would be damaged. He then provided extra safety by
directing traffic and also provided crowd control with all of the damaged cars, tow trucks, Good Samaritans and 0spectators". I plan
on writing the Minnesota State Patrol and letting them know what happened and the good job that he did. I went back the next
day May 11 and thankfully the potholes where fixed. Great job on fixing the potholes right away. See pictures showing where
everything happened and the repaired potholes. __
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The road was unsafe due to the potholes.
The City of Saint Paul should have been more proactive and fixed these dangerous potholes. By not immediately fixing these
potholes is how the City of St. Paul is responsible for my damages. It could have been a lot worse. People could have been seriously
injured._
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 Oty 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.
181 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.
\ Revised March 2023
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6 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
If yes, please provide the police report case number: _23403437 __________ _
If yes, what law enforcement agency responded? _Minnesota State Patrol -see attached card for Trooper James Lee #656
Where did the incident take place? Please provide a street address, intersection or name of city park or facility: St. Clair Exit ramp from southbound 35E. Exit ramp turns into Pleasant Ave. Intersection of Pleasant Ave and St. Albans. See picture of the intersection and repaired potholes.
What would you like to see happen to resolve this claim to your satisfaction? Would like to have my repairs of $616.70 paid for. If the pothole would not have existed or would have been fixed immediatly my car would not have been damaged. I live in Hayward, WI. I was visiting my mother for the night (May 10) who lives on Fairmount Ave in St.Paul and was planning on ret urning to Hayward the next day May 11 but my car wasn't going to be fixed until Friday May 12. It wasn't practical to get two estimates. I had to bring it to the Honda dealership that does all of the work on my Acura. I knew they would do it quickly at a fair price. __
Were there witnesses to this incident? Please provide names and contact phone numbers: Yes there were multiple witnesses. Here are the names and phone numbers for two of the other people who had damaged vehicles. carrie Scheally 651-263-2111 and Maureen Dola 651 ... 357-8128. Also, Trooper James Lee was a witness 763-242-6290. 'Jb[o..,I\
For property damage claims. including vehicle accidents.
Your vehicle's information: Year: _2011_ Make: Acura _____ Model: _n ________ Color: _Black _____ _
License Plate#: ANM 9565. _________ State vehicle is registered in: _WI ________ _
Registered owner of vehicle: George and Susan Yoshida Driver: _George Yoshida ___________ _
Area(s) damaged:_Front right and rear right tires. Alignment ________________ _
If a City vehicle was involved, License Plate#: ______________ Color: ____________ _
Was there Oty 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
Revised March 2023
b miss any work as result of this incident? YES I@)
/
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: 4 pictures of the potholes. One
picture ofTrooper James lee's business card. Receipt showing what was damaged and the cost. _________ _
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 : _George Yoshida ~
Signature of Person submitting this form: -9...:::::.ip"=°~R.&.R.r:.0::..r-A_a_:_,....::::::::~------------
Relationship of person signing to Party making the cla~~ _______________ _
Date document is being signed: V\°7 \'{\ 1--DJ-..)
Revised Mam, 2023