Reiss, JenniferNOTICE 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 ___Jennifer____Last Name ___Reiss_______________
Please Indicate Your Pronouns:She/Her/Hers X 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?Choose an item.If yes,what is your File Number?_______________________________
If yes,then provide your Insured’s/Client’s Name ____________________________________________________________
Street Address:_1108 Grand Ave_Apt 4________________________________________________________________
City:_St Paul__________________________State _MN____Zip Code _55105______
Daytime/Work Phone ___757-773-5696_____Cell Phone __757-773-5696__________________
Date of Incident or Date Discovered (Must complete)_____3/26/23______Time __4:30pm______________
Please state,in detail,what happened that prompted you to file a Notice of Claim Form.__Driving on Victoria St N in St.Paul,
between University &St.Anthony the streets are so torn up with potholes,the roads now have giant craters from one side to the
other along the entire road.My car was unable to avoid these gigantic holes and completely snapped while traveling down the
street.This caused extensive damage.I was even traveling at very slow speeds,but the holes were so twisted and deep,there was
no way around the damage.These potholes are still present,and are very deep running across the entire roadway.There are so
many of them that it actually threw my car into several different directions.There was no way to avoid the giant holes or to drive
around them and this has completely devastated my small car that I use every day to transport my family members,including my
disabled sister to her doctor's appointments.___________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages?___This roadway is way too
dangerous/hazardous to be allowed to be driven.The gigantic holes left unattended have caused extensive &costly damage to
my car.This could/should have been blocked,warned,flagged,and/or patched by now,because of the possible dangers The road
has not been tended to as of yet.____________
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.
X 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.
_On the street of Victoria St.N.running between St Anthony Ave &University Ave W___________________
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?__Payment for the repairs that have to be made to my
vehicle’s suspension for it to be in safe driving condition again.Parts &Labor suspension items included in the estimated repairs
for axle,tie rod,struts and springs in the amount of $1,968.25________________________________
Were there witnesses to this incident?Please provide names and contact phone numbers.__Yes.Allison
Nichols____904-229-9382__________
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year __2009____Make ___Volvo____Model __s40_____Color _Black____
License Plate #____FZR945____State vehicle is registered in __Minnesota_________
Registered owner of vehicle __Jennifer Reiss_________Driver _Jennifer Reiss___________
Area(s)damaged _Alignment &Suspension -Tie rod,struts,springs,axle,sway
bar________________________________________________________________
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.__2 estimates and pictures of
damages and roadways__________________
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:__Jennifer Reiss______________________________________________
Signature of Person submitting this form:_______________________________________________________________________
Relationship of person signing to Party making the claim:____Self____X____
Date document is being signed __4/7/23___________
Revised December 2021