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Evans, Damarion 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: Damarion ________________________________ Last Name: Evans _______________________________________________ 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: 2175 Glenridge Ave_______________________________________________________________________________________________ City: Saint Paul ______________________________________________ State: Minnesota ________________________ Zip Code: 55119___________________ Daytime/Work Phone: __________________________________ Cell Phone: 6125128389 _____________________________________________ Date of Incident or Date Discovered (Must Complete): July 11,2025_____________________________ Time: 10:45am_____________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form: having to get a new tire replaced , due to damage from potholes.____________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____________________________________My tire was damaged due to neglected pothole. Due to this circumstance, I am now having to pay adhere to the damages to my vehicle . 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: Burns and suburban Ave ____________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? Reimbursement for tire , and patchwork done to street ____________________________________________________________________________________________________________ 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 N/A____________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: 2023_________ Make: Nissan_________________ Model: Sentra__________________ Color: White__________________ License Plate #: RKV510_________________________ State vehicle is registered in: Minnesota ___________________________ Registered owner of vehicle: _____________________________ Driver: Damarion Evans __________________________________________ Area(s) damaged:_______passenger back tire _______________________________________________________________________________ If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________ Was there City insignia on the vehicle? YES / NO Driver’s Name</w: NO______________________________________________________ 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? NO___________________________________________________ Was medical treatment received? YES / NO Where? </NO________________________________________________________________ First day of medical treatment? NO_____________ Are you still receiving medical treatment? YES / NO Did you miss any work as result of this incident? YES / NO < Employer(s): NO_________________________________________________________________________________________________ How much time have you missed from work? _____________________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages: _________________________Labor costs 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: Damarion Evans_____________________________________________________________ < Signature of Person submitting this form: Damarion Evans _______________________________________________________ Relationship of person signing to Party making the claim: __________________________________________SELF Date document is being signed: July 11th, 2025_____________________ Revised March 2023