Villela, AnthonyNOTICE 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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon
or other relief demanded.”
Please complete this form in its en1rety by clearly typing or prin1ng your answers to each ques1on. If you have addi1onal documenta1on, you may add those
documents to your submission. You will not be contacted by telephone unless clarifica1on is needed. The claim process for inves1ga1ons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sec1ons 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: Anthony Last Name: Villela
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? YES / NO If yes, what is your Claim/File Number? NO
Is this claim being made by an AHorney? YES / NO If yes, what is your File Number? NO
If yes, provide your Insured’s/ Client’s Name: N/A
Street Address: 929 Stryker Ave
City: St. paul State: Minnesota Zip Code: 55118
DayMme/Work Phone: 651-368-6012 Cell Phone: 651-368-6012
Date of Incident or Date Discovered (Must Complete): April 8th Time: 3:00am
Please state, in detail, what happened that prompted you to file a NoMce of Claim Form: I got a flat Pre last night aQer driving
through the streets of St. Paul, and aQer I went to check out how much Pre looked, I realized that it was just destroyed and I
needed a new one. I pulled over to the side and waited this morning to get it checked out.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I feel that the city is responsible for the
damages done to my car because of all of the potholes I have encountered this year. I usually try my best to avoid them but some
are just hidden to good and or are simply unavoidable.
Please check the reason that most closely describes the reason for your submiXng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiHed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esMmates for repairs or actual bill that has been paid.
✅ Automobile damage from a street defect or pothole: please provide two esMmates 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 Mcket (if available), receipt from Impound Lot, and two esMmates for repairs or actual bill
that has been paid.
☐ Snow Emergency: please provide copy of towing Mcket (if available), receipt from Impound Lot,
and two esMmates for repairs or actual bill that has been paid.
Revised March 2023
☐ Property damage: please provide two esMmates 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.
ConPnue to page 2 of NoPce of Claim Form. Failure to complete and return both pages will result in delays.
This secPon must be completed for all claims.
Is there a police report for this incident? NO
If yes, please provide the police report case number: N/A
If yes, what law enforcement agency responded? N/A
Where did the incident take place? Please provide a street address, intersecMon or name of city park or facility:
Seventh street west going towards downtown St. Paul
What would you like to see happen to resolve this claim to your saMsfacMon?
I would greatly appreciate if the damages done to my car is covered by the city, and also, I hope that I am able to get a check for the
damages so I can make a payment to the people who fixed my Mre this morning.
Were there witnesses to this incident? Please provide names and contact phone numbers:
Gabriela Gaytan - 651-280-8870
For property damage claims, including vehicle accidents.
Your vehicle’s informaMon: Year: 2014 Make: Honda Model: Accord Color: grey
License Plate #:0779BB State vehicle is registered in: Minnesota
Registered owner of vehicle: Anthony Villela Driver: Anthony Villela
Area(s) damaged: all four Pres
If a City vehicle was involved, License Plate #: n/a Color: n/a
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 sMll receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
How much Mme have you missed from work? None
Revised March 2023
If you are submiXng other documents, please state what you are a]aching and how many pages: n/a
By signing this form, you agree that all informaPon provided is true and correct to the best of your knowledge.
Please NOTE that submiXng a false or misleading claim can and will result in prosecuPon under Minnesota Statutes.
Name of Person compleMng form: Anthony Villela
Signature of Person submidng this form: Anthony Villela
RelaMonship of person signing to Party making the claim: none
Date document is being signed: April 8, 2023
Revised March 2023