Trksak, Daniel
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 Daniel Last Name Trksak
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? <No </w </w:t></w:r If yes, what is your Claim/File Number<?: _____________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
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Street Address: _________________________________________________________________________________________
City: ____________________________________________ State ___________________ Zip Code __________________
Daytime/Work Phone _______________________________ Cell Phone 612-226-9821
Date of Incident or Date Discovered (Must complete) 3/18/2023 </w:tTime 9:20 pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I hit a massive pothole that took out both my wheel rims on the passenger side when driving
back from MSP airport to pick up my dad on the Saturday of 3/18. He called a tow from AAA, but after waiting for two hours, he cancelled it because no truck had come yet. We ended up
taking an Uber home, and then on Sunday he drove me down using an extra spare tire from my dad’s Subaru so I could slowly drive it back to our local Tires Plus. I called the St. Paul
police station on Sunday when I saw there weren’t any cones around the hole yet, and they forwarded me to the department that handles potholes. They weren’t available (presumably because
it was a Sunday) so I left a message detailing the pothole and the location.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? This pothole makes the road extremely unsafe to drive on, especially at night when it is even
harder to see. It was not just me that hit this pothole either. While waiting for the Uber at the nearby gas station, three other people’s cars had flats from the same pothole.
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? 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.
Directly in front of the building at: 1742 7th St W St. Paul, MN 55116
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? Monetary compensation equivalent to the damages done to my vehicle (which would be $566.73, the total cost
of damages in the included invoice minus an oil change) and either traffic cones must be put next to the pothole, or it needs to be fixed if neither of those things has occurred yet
to protect other unsuspecting drivers.
Were there witnesses to this incident? Please provide names and contact phone numbers. Only my father and I were witnesses to our car being hit. His phone is 612-206-0393. In the brief
time talking to the other drivers with damaged vehicles before our Uber arrived (About two hours after we hit the pothole while waiting for an Uber at the nearby gas station); neither
he nor I thought to get their phone numbers.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2019 Make Subaru Model Impreza Color Black
License Plate # HNH-525 State vehicle is registered in MN
Registered owner of vehicle Daniel Trksak Driver Daniel Trksak
Area(s) damaged Both passenger wheel rims had to be replaced, and the steering had to be re-aligned.
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. The invoice of the cost of repairing my car (two pages, pdf) and two pictures of the pothole,
one the day of, one on Sunday the day after with a nearby can for reference (two images).
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: Daniel Trksak <
Signature of Person submitting this form: Daniel Trksak
Relationship of person signing to Party making the claim: Same person
Date document is being signed 3/21/2023
Revised December 2021