Reznikova, Vera
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 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 ______Vera______________________ Last Name ___________Reznikova__________________________________
Please Indicate Your Pronouns: She/ Her/Hers✓ He/Him/His ☐_ They/ Them/Theirs ☐
Company or Business Name: _____________________n/a_________________________________________________________
Is this claim being made by an Insurance Company? If yes, what is your Claim/File Number?: ___________n/a__________
Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________n/a________
If yes, then provide your Insured’s/ Client’s Name ________________________n/a____________________________________
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Street Address: _______________________1061 Montreal Ave #214__________________________________________________________________
City: Saint Paul____________________________________________ State ________MN___________ Zip Code ___________55116_______
Daytime/Work Phone _______________________________ Cell Phone ____________651-253-6807________________________________
Date of Incident or Date Discovered (Must complete) ___________2/9/2023__________________Time ______5a.m.___________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _________________damaged suspension on my car it cost me 1,350.66__$_________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____________SHEPART AND ELWAY STREETS INTERSECTION in Saint Paul, BIG POTHOLES._THIS AREA NEEDS
NEW ASPHALT, . ALWAYS POTHOLES YEAR AROUND.______
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 _____________NO_______
Revised December 2021
If yes, what law enforcement agency responded? _______________N/A________________________________________
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
________SHEPPART STREET AND ELWAY STREET INTERSECTION______crosby__________________________________________________________________________________________
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? ______________FIX THE INTERSECTION AND REIMBURSE ME 1,350.66$__please._________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. __________________N/A____________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2007_____ Make ________TOYOTA_________ Model _____CAMRY_______________ Color ____________BLACK____
License Plate # _________MRJ 873___________ State vehicle is registered in _____________MN___________
Registered owner of vehicle ______________________________ Driver ____________Vera Reznikova__________________________
Area(s) damaged _______________front suspention, shocks, struts__________________________________________________________________
If a City vehicle was involved: License Plate # __________n/a_____________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________n/a________________
Other property damaged: n/a___________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _____________________n/a_____________________________________________________
Did you go to the emergency room or urgent care? Yes No Where? N/a_________________________________________________
Was medical treatment received? Yes No Where? _____________________n/a_________________________________________
First day of medical treatment? _____n/a________ Are you still receiving medical treatment? Yes No
Did you miss any work as result of this incident? Yes No Employer(s) _________________________yes______________________
How much time have you missed from work?___________8 hours________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages. __________invoice, picture of potholes.____________
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: ___________________Vera Reznikova_____________________________
Signature of Person submitting this form: _____________Vera Reznikova__________________________________________________________
Relationship of person signing to Party making the claim: _________n/a__________
Date document is being signed ________2/14/2023_____
Revised December 2021