Reeder, Donald (2)NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Stotute 466.05 stotes thot ".".every person...who claims damoges t'rom any municipolity...sholl couse to be presented to the governing bady of the
municipolity within 180 days after the olleged loss or injury is discovered a notice stoting the time, ploce, ond circumstances thereof, ond the omount of compensation
or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answers to each question. lf you have additional documentation you may add those
documents to your submission. You will not be contaded 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 Citv Clerk's Office. You may email. fax
(651-26&8574) or mail the form. Mailing address is "Saint Paul City Clerk, 15 West l(ellogg Blvd., Suite 310, Saint Paul, MN 55102"
lndividuals: First Name: Donald Last Name: Reeder
Please lndicate Your Pronouns: She/ Her/Hers I He/Him/His X_ fhey/ Them/Theirs X
Company or Business Name
ls this claim being made by an lnsurance Company?lf yes, what is your Claim/File Number?:
ls this claim being made by an Attorney? NO lf yes, what is your File Number?
lf yes, then provide your lnsured's/ Client's Name
Street Address: 1290 Blair Avenue
City: Saint Paul State: MN Zip Code: 55104
Daytime/Work Phone: 651-645-7894 Cell Phone: 612-559-2985
Date of lncident or Date Discovered (Must completel:3/t312O23 Time: Afternoon
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. After I hit a series of potholes, an odd
thumping noise started. At first it was small but it got louder. Then a large piece of plastic fell out of the wheel well while I was
driving.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The damage to my car was caused by
potholes in Saint Paul city streets. I had hit a series of large potholes prior to the car part falling out of the wheel well.
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 ofSaint Paul and shall not be returned.
E Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
EI Automobile damage from a street defect or pothole , pl""r" provide two estimates for repairs or actual bill that has been paid.
fl Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from lmpound Lot, and two estimates for repairs or actual bill that has been paid.
E Snow Emergency: please provide copy of towing ticket (if available), receipt from lmpound Lot, and two estimates for repairs or
actual bill that has been paid.
E Property damage: please provide two estimates for repairs or actual bill that has been paid.
E You were injured during a motor vehicle accident: please provide police report number, details about injury.
n 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.
ls there a police report for this incident? NO lf yes, please provide the police report case number
Revised December 2021
lf 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.
ln Como Park, on Lexington Avenue, between the north entrance to the pavilion and the south entrance to the pavilion.
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? Pay for the repairs to my car
Were there witnesses to this incident? Please provide names and contact phone numbers. Bonnie Reeder, 651-545-7894
For propertv damase claims, including vehicle accldents.
Your vehicle's information: Year: 2020 Make: Nissan Model: Altima Color: Gray
License Plate #: KMG-289 State vehicle is registered in: MN
Registered ownerof vehicle: Donald Reeder Driver: Donald Reeder
Area(s) damaged: Right-front wheel well
lf a City vehicle was involved: License Plate # Color
Was there City insignia on the vehicle? Yes No Driver's Name
Other property damaged :
For iniurv claims of anv tvpe.
What part of your body was injured? Not applicable
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? None
lf you are submitting other documents, please state what you are attaching and how many pages. Repair invoice for my car from
Kline Nissan, one page
By signtng this form, you agree that ott informotion prouided is true and sorrect to the best of your knowledge..
Please NOTE that submitting a false or misleading claim cdn and will result in prosecution under Minnesota Statutes,
Name of Person completing form: Donald G. Reeder
Signature of Person submitting this form zt) ,1 -/.: tl.-/-,-,<4.4-l//'E r.{,",-
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3lX/2A23
Revised December 2021