Venning, AlexanderNOTICE 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 City Clerk’s Office. You may email, 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 _Alexander ________ Last Name _Venning__________________
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? NO If yes, what is your Claim/File Number?: _____________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: __2219 Eleanor Ave_______________________________
City: _St. Paul_________________________ State _Minnesota__________________ Zip Code _55116________________
Daytime/Work Phone _804-512-0514_____________ Cell Phone ____________________________________________
Date of Incident or Date Discovered (Must complete) 3/18/2023Time _11:30am_________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _I drove north on Cretin Ave in Highland
Park. I typically try to avoid the numerous potholes by bearing left into the southbound lane whenever possible, but I was unable to
because of oncoming traffic, so I had to drive over several potholes. Despite slowing down through this section, after returning
home, I discovered my front right tire had gone flat. After taking it to the mechanic, I was informed that the left front tire had also
sustained damage consistent with pothole impacts and was likely to blow if it was not replaced. As a result, I had to replace both of
my front tires because of driving over potholes on Cretin Avenue.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _Cretin Avenue has been full of potholes for
weeks and has not been repaired. The northbound section of road immediately north of Ford Pkwy is particularly bad, with several
sections of potholes stretching across the entire lane and some deep enough to see exposed bricks under the road.
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.
This section must be completed for all claims.
Is there a police report for this incident? No If yes, please provide the police report case number ____________________
Revised December 2021
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.
________________________________________________________________________________________________________
Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your satisfaction? _I would like to be reimbursed for the cost of replacing
my tires.
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 2011_ Make _Hyundai___ Model _Elantra____ Color _Silver______
License Plate # _345-WUD______ State vehicle is registered in _Minnesota____________
Registered owner of vehicle _Alexander Venning_______ Driver _Alexander Venning______________
Area(s) damaged _Front tires__
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. ______________________
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: _Alexander Venning____________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: ___________________
Date document is being signed _____________
Revised December 2021