Maas, ReneeRECEIVED
f=';AR G6 2023
NOTICEOFCLAIMFORMtotheCityofSaintPaul,Minnesota CITY CLERK
Mrnnesoto State Statute 466.05 states that":..every person...who dafms damages fu:rm any municipolity...shallcause to be presented to the governing body of the
municipality within 180 days after the alleged loss or rnjury /s discovered a notice statlng the t(me, phace, and circumstances thereof, and the amount of compenwUon
or other relief demanded."
Please completa this form In Its entirety by dearly 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 investlgatlons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission Is to the Saint Paul City Clerk's Office. You may ,email fax
(651-266-8574) or mail the form. Mailing address is "Saint Paul City Clerk, IS West Kellogg Blvd., Suite 310, Saint Paul, MN 55102"
Individuals: First Name R55353 Last Name MBI
Please Indicate Your Pronouns: She/ Her/Hers C He/Him/His a. 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 belng made by an Attorney? NO If yes, what is your File Number?
If yes, then provide your Insured's/ Client's Name
Street Address: 1866 St. Clair Avenue
City:StateMN ZipCode
Daytime/Work Phone (612) 669-2547 Cell Phone
Date oflncident or Date Discovered (Must complete) 3/2/2023Time 9:00 pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form, Hit a pothole requirinH new tires
Please state why or how you feel the City of Saint Paul is responsible for your Damages? This pothole has been there for 6-8 weeks.
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.
IJ 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.
Isthereapolicereportforthisincident? Nolfyes,pleaseprovidethepolicereportcasenumber
Revlsed December 2021
If yes, what law enforcement agency responded?
Where did the incident take place? Please provide a street address, intersectlon or name of City park or facility.
On Howell Avenue about 50-100' South of St. Clair
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 to be reimbursed for the new tires that
were required to be purchased due to this incident. This is an AWD vehicle, which requires all4 tires be replaced at the same time.
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 2Q!! Make Subaru Model Color
License Plate State vehicle is registered in
Reglstered owner of vehicle Renee Maas Driver Renee Maas
Area(s) damaged Front passenzer side tire
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? No Where?
Was medical treatment received? No Where?
First day of medical treatment?Are you still receiving medical treatment? No
Did you miss any work as result of this incident? No Employer(s)
How much time have you missed from work? n/a
If you are submitting other documents, please state what you are attachlng and how many pages. Receipt: 1 page & Photo: 1 page
8y signing this form, you agree that a// information provided is true and correct to the best of yourknowledge.
Please NOTE that submitting a fdse or misleading daim can and will resu/t in prosecution under Minnesota Statutes.
Name of Person completing form:
SignatureofPersonsubmittingthisform: QHp.,l'[4a
Relationship of person signing to Party making the claim: Self
Date document is bein@ signed 3/6/2023
Revised December 2021