Xiong, GeorgeNOTICE 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 Saint 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: George
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? _________________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: 1640 Clarence Street
City: Saint Paul State: Minnesota Zip Code: 55106
Daytime/Work Phone: 612 245 5406
Cell Phone: 612 245 5406
Date of Incident or Date Discovered (Must Complete): March 5th, 2026
Time: 6:43 am
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:
I was driving on a public street in Saint Paul when my vehicle struck a pothole located in the roadway. And upon impact, the pothole
caused immediate damage to my tire, resulting in a flat tire. For this reason, I am submitting this Notice of Claim to request
reimbursement for the cost associated with repairing or replacing the damaged tire.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
I believe the City of Saint Paul is responsible for my damages because the pothole that caused the flat tire was located on a
city-maintained roadway and created a dangerous condition for drivers. While driving my vehicle normally, my tire struck the
pothole, which caused immediate damage and resulted in a flat tire. The pothole was significant enough to damage my vehicle and
posed a hazard that could not be safely avoided while traveling in the lane of traffic. Proper roadway inspection, maintenance, and
timely repair of the pothole could have prevented this damage.
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.
$93-280
Revised March 2023
☐ 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: ___________________________
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:
The pothole is on White Bear Ave before the corner to Bush Ave.
What would you like to see happen to resolve this claim to your satisfaction?
I would like a reimbursement for the cost associated with repairing or replacing the damaged tire. A Proper maintenance, and timely
repair of the pothole so a incident like this can be prevented.
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: 2025 Make: Toyota Model: Camry XSE Color: Metallic Grey
License Plate #: ZHD 748
State vehicle is registered in: Minnesota
Registered owner of vehicle: George Chue Xiong Driver: George Chue Xiong
Area(s) damaged: Front passenger Tire
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
Revised March 2023
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: _________________________
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 Chue Xiong
Signature of Person submitting this form: George Chue Xiong
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: March 5th, 2026
Revised March 2023