Ciaschini, ShannonRevised March 2023
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 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: ____Shannon____________________________ Last Name: Ciaschini
_______________________________________________
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?
___No______________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number?
No_______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: 1091 Goodrich Ave #14
_______________________________________________________________________________________________
City: St Paul______________________________________________ State: MN Zip Code: 55105
Daytime/Work Phone: __________________________________ Cell Phone: 651.274.7526_____________________________________________
Date of Incident or Date Discovered (Must Complete): 4/12/2023 Time: 10:15am
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___Ran over pothole on West 7th St
damaged front of my vehicle_________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Pot hole so deep it showed the old trolly
rails____________________________________
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.
Revised March 2023
☐ 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 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:
West 7th Street between Montreal and
Lexington____________________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
__Reimbursed for damage to my
vehicle______________________________________________________________________________________________________
____
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________________________________________________________
No
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: __2015_______ Make: CL250_________________ Model: Mercedes__________________ Color:
Grey__________________
License Plate #: __JPL 089_______________________ State vehicle is registered in: _____MN______________________
Registered owner of vehicle: _______________Shannon Ciaschini______________ Driver: Shannon Ciaschini
__________________________________________
Area(s) damaged:Front tires and
rims______________________________________________________________________________________
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): _________________________________________________________________________________________________
Revised March 2023
How much time have you missed from work?
___N?A__________________________________________________________________
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: _____Shannon Ciaschini________________________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: _____________________
Self
5/11/23