Tenaye, BerekatNOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota
Minnesota State Statute466.05 states that “…every person…whoclaims damages from any municipality…shallcause to be presented tothe governing body of the
municipalitywithin180days after the allegedlossor injury is discovered a notice stating thetime,place,and circumstancesthereof,and the amount ofcompensation
orother relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question.If youhave additionaldocumentation you may addthose
documentsto your submission.You will not be contacted bytelephone unless clarification is needed.Theclaim process for investigations can take upwardsof
four(4)weeks.This form mustbesigned,dated with all applicable sections completed.Submission isto the Saint Paul City Clerk’s Office.You may email,fax
(651-266-8574)or mail the form.Mailing address is “SaintPaul City Clerk,15 WestKelloggBlvd.,Suite310,Saint Paul,MN 55102”
Individuals:First Name Bereket Last Name Tenaye
Please Indicate Your Pronouns:She/Her/Hers ☐He/Him/His ☐_They/Them/Theirs ☐
Company or Business Name:NA
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:2047 Saunders Avenue
City:Saint Paul State:MN Zip Code 55116
Daytime/Work Phone _______________________________Cell Phone 6514439315
Date of Incident or Date Discovered (Must complete)March 13/2023 Time 11:53 AM
Please state,in detail,what happened that prompted you to file a Notice of Claim Form.I drive through Cretin Avenue to go to
school 5 days a week.In the first week of March,I was driving on that road and there were big potholes.I tried to avoid it but other
cars were coming and close to the right hand curb is even worse.So I drove over the pothole.My car started acting weird since then.
The steering wheel started shaking,and I hear squeaking sound when I steer while parking.I thought rebalancing the tires would fix
it but it didn’t.I went to Midas for oil change on .And they told me my front struts are bad.I was not able to get itMar 13, 2023
fixed since it was super expensive for me.I recently found out that I can claim such damage so I am filling this form.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?There are no warning signs on the roads for
those big holes.I have seen reflective cones on other roads where potholes are bad.The city did not even try to temporarily fill the
potholes until the weather gets warmer.The city could also have required no street parking until the potholes are fixed,and help us
avoid the potholes.
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?Yes 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.
Cretin avenue between Ford Parkway and Randolph
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 the city to look at the estimates I provided
and give me money to get the car fixed.
Were there witnesses to this incident?NO Please provide names and contact phone numbers.______________________________
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year 2012 Make Kia Model _____Forte_______________Color ____Red________
License Plate #___BJY024__________________State vehicle is registered in ____MN____________________
Registered owner of vehicle ____Bereket Tenaye_________________Driver ________Bereket Tenaye_____________
Area(s)damaged _______________Front Struts,Sway Bar Link,Thrust Alignment___________________
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.Estimates of Maintenance 3
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:__________Bereket Tenaye______________
Signature of Person submitting this form:________Bereket Tenaye_________________________________________
Relationship of person signing to Party making the claim:____It is for myself_____
Date document is being signed ____04/05/2023__
Revised December 2021