Rodriguez, Alexis
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 is to the Saint Paul
https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may
mailto:cityclerk@ci.stpaul.mn.usemail, 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 _ALEXIS_______________ Last Name __RODRIGUEZ___________________________________
Please Indicate Your Pronouns: She/ Her/Hers X He/Him/His ☐_ They/ Them/Theirs ☐
Company or Business Name: _________N/A_______________________________________________________________
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 </w:tIf yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name _________________________________________________________
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Street Address: __582 GREENWAY AVE N_______________________________________________________________
City: __OAKDALE___________________________ State __MN_____________ Zip Code __55128______________
Daytime/Work Phone __(651)556-0687_________ Cell Phone ____(763)352-6188_________________________________
Date of Incident or Date Discovered (Must complete) ___1/26/23_______________Time _______00:43______________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _POLICE VEHICLE REAR ENDED MY VEHICLE WHILE MY VEHICLE WAS STOPPED AT A STOP SIGN____________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _THE POLICE VEHICLE WAS TRAVELING FASTER THAN IT SHOULD HAVE BEEN ON THE SIDE ROADS THAT WERE
VERY ICY DURING THIS WINTER TIME___________
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.<
X 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? X-Yes No< If yes, please provide the police report case number __23-014028_____________
Revised December 2021
If yes, what law enforcement agency responded? __ST PAUL POLICE DEPT________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
AT THE CORNER OF FLANDRAU & JESSAMINE AVE, ST. PAUL, MN 55106
________________________________________________________________________________________________________
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? _RECOVER MY RENTAL EXPENSES & MY INSURANCE OUT OF POCKET DEDUCTIBLE TO REPAIR MY VEHICLE DAMAGES ________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. _OFFICER STING YANG (651)703-6818____________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2010_____ Make _CHEVROLET_____ Model _SUBURBAN__ Color __BLACK______
License Plate # _3CN828_____________ State vehicle is registered in ___MN_____________________
Registered owner of vehicle _ALEXIS RODRIGUEZ_ Driver ___ANTHONY RODRIGUEZ____________
Area(s) damaged __RIGHT REAR END TAIL-LIGHT, REAR BUMPER & REVERSE SENSORS _________________________________________________________________________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________</w
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. _____5 TOTAL_____________
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: ___ALEXIS RODRIGUEZ___________________________________________
Signature of Person submitting this form: ______________________________________________________________________
Relationship of person signing to Party making the claim: ____SELF/OWNER_________
Date document is being signed ___5/8/2023__________
Revised December 2021