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Hofschulte, Anna - resent 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 Anna ____________________________ Last Name Hofschulte_____________________________________________ 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? ____ If yes, what is your Claim/File Number?: _____________________ Is this claim being made by an Attorney? _________ If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ </ Street Address: 1251 Barclay Street_________________________________________________________________________________________ City: Saint Paul____________________________________________ State MN_______________________ Zip Code 55106__________________ Daytime/Work Phone _______________________________ Cell Phone 651-373-3920, 651-424-2223 Date of Incident or Date Discovered (Must complete) _03-21-2023 8:30 PM____________________________Time _________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. On the way to taking me to ER my grandma was driving and hit a pot hole on 7th and cedar by the construction barriers and blew her tire and the wheel got locked up. Needed to get a tow truck to get home_____________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? There are so many potholes on these roads and alot of them you cant even see til its too late, plus the construction barrier that was there guiding you to move over to the left turn lane until getting through the intersection guided her right into the pot hole ______________________________ ______________________________________________________________________________________________________ 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. _x__ Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid. _x__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? Yes No If yes, please provide the police report case number ____________________ Revised December 2021 Notice of Claim Form, page two. Failure to complete and return both pages will result in delays. 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. 7th Street E and Cedar ave______________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? Compensation for the damages and tow cost_________________________________________ ________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________ ________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year 2005________ Make chevy_________________ Model impala____________________ Color grey________________ License Plate # GMR-031_____________________ State vehicle is registered in Minnesota ________________________ Registered owner of vehicle Anna Hofschulte______________________________ Driver Anna Hofschulte______________________________________ Area(s) damaged front driver side wheel___________________________________________________________________________________ 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 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. Picture of the hole in the tire, reciept from the shop and the tow receipt, and 2 pictures of 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: Damian Hofschulte ________________________________________________ Relationship of person signing to Party making the claim: Filling this out for my Grandmother_________________________________________________________ Date document is being signed 4-17-2023________________________ Signature of Person submitting this form: Damian A Hofschulte_______________________________________________________________________ Revised December 2021