Bohdan, DeniseNOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
MiMesota State Statute 466.0S states that " .. e•'f!,Y ~rson ... who claims damages from any m11nic1pality .. shall cause to be pn,se11ted to the go>'tming bod)• of tht
municipality within /80 days after tht alltgtd loss or injury is disco\'f!fl!d a notice stating the time, plau, and c,rcumstances t/,e~of. and tire amount of comptnsat/011
or other ~lief demandtd. "
Please complete this rorm In lls entirety by clearly typing or printing your answers to each question. Ir you have additional documenlJllion, you may add those
documents ta your submission. You will not be conlJlcted by telephone unless clariRc:atlon Is needed. Tbe claim process for Investigations can lake upwards or
four (4) WHks. This form must be signed, dated wllb all applicable sections completed. Submission Ibis completed form to the Spjnl Pauj Citv Psck', omcc
by email (cltyclerk@cl.slpaul.mn.us), rn (651-26<,-8574) or mall addressed to wsalnt Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN
• 55102".
Claimant: First Name: b e,.;1; 5-e,. Last Name: &/4.da/?
Please Indicate Your Pronouns: )(She/Her/Hers, D He/Him/His, D They/ Themffheirs
Company or Business Name:----------------------------------------
Is this claim being made by an Insurance Company? YE~fyes, what is your Claim/File Number?
Is this claim being made by an Attorney? YES (@ryes, what is your File Number?
If yes, provide your Insured's/ Client's Name:
Street Address: ~2a._..i.Q...J,..,1.l>-=e,..c.::c:..,..... ________________________ _
City: ~&~--'·-..&P__.a ........ J...-:....,:. ______ State: _____..fM..........,,._,4-1,<--J ___ Zip Code: 5 5/t> 6
Daytime/Work Phone: ___________ Cell Phone: 2CJtj-770-00 0 /
;:;:: :: :_;:;;;~ ;;~;:...20:1--"5 bc:tle-i:S~wr~ C o:t-C!sli' cl£a).,,A)u ,P) : -i>~-/~2023
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: S-e {2. ~a.l1Jll1'.R.d
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ---8 (Jo
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.
o Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
~utomobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid.
o 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.
o 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.
o Property damage: please provide two estimates for repairs or actual bill that has been paid.
o 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.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
Ibis secttop must be completed for all claims.
ls there a police report for this incident? YEs@
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: s~-~
Were there witnesses to this incident? Please provide names and contact phone number~ ,ff ,"2.
~N:itrm ~~,'t1 /JftS~ .h.u±4<,! (?.c_/~
For 1!.[21!£.l:!Y. damage claims, including vehicle accidents.
Your vehicle's information: Year: dDfi Make: flyuJ1da~ Model:&~& Color:~k
License Plate#: :Dl,12-3bC} State vehicle is registered in: _,_/)1,LIO'/V,__,,_ _______ _
Registered owner of vehicle: D-eni<.R 6oltt&an Driver: b:s1.. 13 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:--------------------------------------
&a:.lnillD' claims or any txR£:
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 su~mlttiog ofher documents, please state what you ar~ attaching and bow mn~y !~!s: -~,r t;rLL~2.. _TltltJde.Kj-cieSCAJj<070J/I-=-I~
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: ~JI l0
S-.f Bo~
Sign,nue of P•~•• submitting !hi, fom,, _
Relationship of person signing to Party making the claim: -~Sg/£~==-=-..:...__ __________ _
Date document is being signed: /2-2/p -2..0 2-3 Revised Marrh 2023
Customer Number:1126626 Invoice No: 370453
*INVOICP
DUPLICATE 1
~l~~~~i'fi
• 111•MU0TA·s ,u111u NTUIIDAI PULU
3350 HIGHWAY 61 DENISE BOHDAN
60 MARiA AVE
SAINT PAUL, MN 56106-6307
Home: 209-770-0001 Bus:
Page 1 of 2.. VADNAIS HEIGHTS -ST. PAUL, MN 55119
(651) 490-6699
Cell:
E-mail: email j lndeway@gmail com .
COLOR YEAR MAKE/MODEL VIN LICENSE MILEAGE IN / OUT TAG SERVICE ADVISOR 6 BRIAN COYLE
Other 14 HYUNDAISANTAFESPO 5XYZTDLB1EG149876 1 34534 / 134539 T6213
DEL DATE PROD. DATE WARR. EXP. PROMISED PONO. RATE PAYMENT
11MAY23 18:00 14DEC23 199.99 CC4
A.O. OPENED READY OPTIONS:
.
09:43 14DEC23 14:18 15DEC23 LINE OPCODE TECH TYPE HOURS LIST NET
A PERFORMED WHEEL ALIGNMENT ADJUSTED ANGLES TO SPECIFICATIONS ROAD TESTED CAUSE: WHEEL ALIGNMENT MEASURE AND ADJUST ANGLES TO SPECIFICATIONS
4AH PERFORMED WHEEL ALIGNMENT ADJUSTED ANGLES TO SPECIFI·CATIONS ROAD TESTED 30 CR 139.99
134534 4 WHEEL ALIGNMENT COMPLETE ************~*************************~************* B Performed rear brake job and machine rotors. Cleaned lube Pins and Slides CAUSE: Perform rear brake job and machine rotors. 27RM Performed rear brake job and machine rotors. t • • • • • ... .,. Cleaned lube Pins and Slides • ,,. 30 CR " 1 58302-2WA00 PAD KIT-REAR DISC BRAKE 112.76 229.99 112.76
134534 REPLACED REAR BRAKE ~ADS~ W--\,q~IN~v~~ ROTO~S ** * * * * * * * * ** ***** **"'***-:"-**-Ii* ***jt* *·* * * ** **-* * * * * * * * ** * *
C CUSTOMER STATES996 -UNDERBODY .CORROSION PREV.SVC.(23-01-063H) CAUSE: RECALL UNDBRCAOTING COMPLETE • • , , 30O059R0 UNDERBODY RUST INSP & PREVENTIVE SERVICE 300 WNF i • ;~ ~; /;; ::: ,?i (,..,::. f;
134534 COMPLETE *********************************************~******
D PERFORM COMPLIMENTARY MULTI-POINT INSPECTION, CUSTOMER COURTESY AT A
$49.99 VALUE CAUSE: PERFORM COMPLIMENTARY MULTI-POINT INSPECTION, CUSTOMER COURTESY AT A $49.99 VALUE INSP PERFORM COMPLIMENTARY MULTI-POINT INSPECTION, CUSTOMER COURTESY AT A $49.99 VALUE
30 IPS4 ****************************************************
WAIIRA1fi! Dl~MJIILAU. l"AIITI AND ACCEIIORIES ARI BOLD AND AU R!PAIIIS AR~ •SHOP SUGiPL V C~STSi DESCRIPTION PilbvibW if EDrEMHII" ~-THE D£ALMIHIP HEREIY EXJltlEIIILY Dl~MI AU We have • a.a a C ar;a wAJIIIAHTIU. EXt'IIUS MD m. INCLUDING ANY IMl'UED WAR !I Of equal to 9.6% of tht LABOR AMOUNT ERCHANTAIIIJTY AHO FITNESS FOIi A PARTICUI.AA P(IIIJIOIE. AHO NEITHER AIIUM!I NOR ~~El N1Y OTH8' l'SISON TO ASSUME fOR IT ANY UAIIUTY IN CONNECTION WITH THE total coat of labor and PARTS AMOUNT IAL2 o, ,ARTS OR PflOOUCTI 011 THE REPAIR. THE ONLY WAMANTIEI ON l"AJITI AN!) parts, not to •~ad
ACCi!NOflllS 011 IIIPAIRS ARE THOSE WHICH MAY II OFRMO IV THE VEHICLE t30.00, to the Repair GAS, OIL, LUSE
r,ANUFACTUll!fl 011 THE ,ARTS MANUFACTURER 011 DIITNIUTOII ANO ONLY SUCH Orcjer for 1hop 1uppli11 SUIILET AMOUNT MANUPAC'TURfJt OIi DIITRIIUTOJI SHAU. IE UMU: FOIi l"ERFOIIMANCE UNDER IUCH u11d In coMtctlon with wAMNfTIES, CUITOMBI SHAU. NOT It BfTlTUD TO RECOVER FROM THE D!AlERIHIP ANY cOHlaJUSfTW. DAMAOQ. DAMAGES TO rROPSm', DAMAOEI FOIi LOU OF UH. LOU OF thia repair. MISC. CHARGES •
TIM!. LOU OF ,110FIT OR INCOME, 011 ANY OTHEII INCIDENTAi. DAMAGU. ALL PARTS ARE NEW TOTAL CHARGES By algnlng below, you acknowledge that you were notified of and authorized the
oealerahlp to perform tht services/repairs Itemized in this Invoice and that you received ORIGINAL EQUIPMENT LESS INSURANCE (or hid the oppo"unlty to l111p1ctl enrc replaced parts II requested by~ou. The v1hlcla PARTS UNLESS
Is belna returned to vou In 11xch1nae or vour oavment of tht Amount ue. OTHERWISE INDICATED, SALES TAX
DATE CUSTOMER SIGNATURE AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE PLEASE PAV THIS AMOUNT
io1•c•-.u, llfll>IIOVICl-lnl'll•IIIX ............ ,_ CUSTOMER COPY
INV, DATE
15DEC23
TOTAL
229.99 112.76
(N/C} (N/C} (N/C)
(N/C)
TOTALS
customer Number:1126626 Invoice No: 370453
*INVOICE*
DUPLICATE 1
~~~V8~ilfi
" NIUUOIA'S ,UNIU "UOAI IO~U
3350 HIGHWAY 61 DENISE BOHDAN
60 MARIA AVE
SAINT PAUL, MN 55106-6307
Home: 209-770-0001 Bus:
Page 2 of 2 VADNAIS HEIGHTS· ST. PAUL, MN 56110
(661) 490-6699
'
Cell:
E-mail: email I indeway@gmall.com .
COLOR YEAR MAKE/MODEL VIN LICENSE MILEAGE IN / OUT TAG SERVICE ADVISOR· 6 BRIAN COYLE
Other 14 HYUNDAI SANT A FE SPO 5XYZTDLB1EG149876 134534 / 134539 T6213
DEL. DATE PROD.DATE WARR. EXP. PROMISED PO NO. RATE PAYMENT
11MAY23 18:00 14DEC23
R.O. OPENED READY OPTIONS:
09:43 14DEC23 14:18 15DEC23 LINE OPCODE TECH TYPE HOURS
E COMPLIMENTARY CAR WASH $5.95 VALUE CAUSE : COMPLIMENTARY CAR WASH $ 5 . 9 5 VALUE WASH COMPLIMENTARY CAR WASH $5.95 VALUE 30 IPS4
199.99
LIST
**************************************************** F** TECH FOUND BOTH FRONT SWAY BAR LINKS LOOSE INFO REPALCED BOTH FRONT SWAY BAR LINKS 30 CR 2 54830-2W000 LINK-STABILIZER 134535 REPLACED BOTH FRONT SW~Y BAR LINKS 134.98
**************************************************** G** TECH FOUND BOTH FRONT LOWER BALL JOINTS LOOSE INFO REPLACED BOTH FRONT LOWER·BALL .JOINTS 30 CR
2 54530-3Sl00 BALL JOINT ASSY-LWR ARM 134535 REPLACED BOTH FRONT LOWER BALL JOINTS 126.52
*********************~****************************** H** TECH FOUND RIGHT FRONT DRIVE AXLE LEKAING INFO REPLACED RIGHT FRONT DRIVE AXLE 30 CR 1 HY8236 CV SHAFT 284. 00
CC4
NET
199.99
134.98
399.98 126.52
259.99 284.00 134535 REPLACED RIGHT FRONT D~IYE,¥-LE _, , ** * * * ** * *** * ** **•**** *~*•:~•*A**,**•**•***** ***.:t ** * * * * * * ** CALL CENTER APPOINTMENT
CREATED 2023-11-13 09:0 2:00AM TAKEN BY CHERYL HANSON NO WIND SHIELD WA SHER FLUID IT LEAKS WILL BE REPLACING IT SOON
INV. DATE
15DEC23
TOTAL
(N/C)
199.99 269.96
399.98 253.04
259.99
284.00
W~RANfV DISCI.NM.1!!_:_ AU. ,AIITS AND ACCESIOIUES ARE SOLD AND AU. REPAIRI AIIE •SHOP SUPPLY COSTS: PROVIOEb if TRE bfAW\SHIP THE OEALBISHIP HERUY EXPIIEIILY DIICLAIMI AU. We have added I charge r,-:-::;::D=::ES:'.C::R7:IPTl-:=-O:.:.N_-,f"7--~~~---
WAIUIANTl~1J:"~~ RT~J. FOIi AED;AIITl~~~R~ =~u:r,.:_~~= Ng: 1qu1I 10 9.5% of the LABOR AMOUNT =~ES AHY OTHER ,EASON TO ASSUME FOR IT AHY UAIIUTY IN CONNECTION WITH THI total coat of labor and t-;;-PA:-;R;:;T:;S-:A:;MO~UN::;:T;-----~----!.~~.i..g!:L_ OF ,Allff 011 l'ROOUCTS OIi THE IIEPAIII. THE ONLY WAIUIANTIU ON PARTS AND pana, not to axcHd r,::-;--::;;;~-;:;:'-----h---..;l.l.iZ...1..Q__
ACC£510IIIES OR IIEPAIAS AM THON WHICH MAY 11£ OPPEIIED IY THE VotlCLE t30.00, to the R1p1lr~G::AS='-;:O~IL7.'::LU::B::E::---h----_JJ.~~-MANUfACTURDI OR THI! ,AIITS MANUFACTUIIEII 011 OISTIUIIUTOII AND ONLY IUCH Order 101 ahop suppllea I
M~11~s<roM:=~~T 5:U-oo~~Ol.£ IIE~ii~g:M:i~~HIPS~~ UHd In connection with r.:SU:;B::L~ET;:A::M:;O~U::N~T::--+i-----__.!l.l..J~~ :OHIEQUENTW. DAMAGES, DAMAOEI TO PROPERTY, DAMAGU FOIi LOSS Of USE. LOIS OF!-th-;;la~r;-ep;;-;a;-;lr:;. ;:-:::-;-::;:;::;-{-:;M;;::l:;SC~.~C;:;H7:AR:';:O::E;:S;:-•--hr---=--....!.,W,IJ.L_ TIME. LOSS Of P'IIOAT OR INCOME. OIi ANY OTHEII INCIDl!NTAL DAMAGES. AL TOTAL CH ,. s below, you that you were notified of and authorized the L PARTS ARE NEW ~==::-:A:::R:-:u:::E::S--+i------'JL!t.~l.JJ.~ to perform the 11rvlc11/repalra itemized In this Invoice end thlt you received ORIGINAL EQUIPMENT I LESS INSURANCE tor thl opportunity to lnapectl any replaced pan, 111 requ11t1d by you. The v1hlcl1 PARTS UNLESS r,:-;;-::'-;-::-.,;,;.;.;;.;;_ ____ n ___ --::=¥~~-ls beln retumed to ou In e fo, our a ment ol the Amount Due. OTHERWISE INDICATED, SALES TAX
DATE CUSTOMEII SIGNATVAE AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE PLEASE PAY
THIS AMOUNT
JOl•C'DI OtaNr. lLC 11111,i 118'11Ct IIINOACI nn I il111C .,.,,,. lilf __,,. CUSTOMER COPY
$ 2226.73
December 26, 2023
St Paul City Clerk
15 W. Kellogg Blvd, Suite 310
St. Paul, MN 55102
At the end of last winter and throughout the first months of 2023, during
my daily commute to work, I unavoidably and repeatedly hit many very large and
severely jarring potholes throughout St. Paul. I explored every possible route,
seeking a smoother one, but each was more devastating than the last.
During that time I also began hearing a rattling/clunking noise emanating
from under my car. The car seemed to still drive though, so I assumed it to be
something innocuous.
On December 14th, 2023 I took my car to Buerkle Hyundai on Hwy 61 to
have routine maintenance done (replace brake pads) and to have recall work done
(underbody coating). During the mechanics inspection they found that the source
of the noise I had been hearing ever since crashing through potholes was
dangerously loosened sway bar links, lower ball joints, and damaged right front
axle -all needing to be replaced to make my vehicle safe to drive.
I am requesting re-imbursement in the amount of $1883.98 ($2226.73
minus the cost of brake pad replacement which was routine and expected -see
copy of receipt). The front sway bar links, ball joints and right front axle were all
damaged from long term, very large potholes. I did not hit anything else.
The worst potholes I ran into were on:
*Burns Ave between Hwy 61/10 and White Bear Ave
*The intersection of Payne/Maryland Ave
*Many locations along Payne Ave between Maryland and Phalen Blvd.
*Intersection of Earl/Magnolia
I understand last winter was unusually fierce, and the potholes were
beyond atrocious, weren't repaired for months, but I feel the city is still liable for
the damage sustained.
I moved back to MN to help take care of my elderly mother and had to max
out a credit card to pay for the necessary repairs to my vehicle to make it safe to
drive again and before I could allow her back in it and be able to take her to
appointments etc.
Thank you in advance