Forsberg, Raya
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 this completed form to the
mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint 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: Raya Last Name: Forsberg
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? YES / NO If yes, what is your Claim/File Number? <NO
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? NO
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: 1742 Dominion Avenue
City: Shakopee State: MN Zip Code: 55379
Daytime/Work Phone: 612-979-5309 Cell Phone: 612-979-5309
Date of Incident or Date Discovered (Must Complete): 3/25/2023 Time: 10:00 p.m.
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: My vehicle has badly damaged from going over a large pothole in the middle of the road that was
unavoidable and dangerous enough to cause thousands of dollars’ worth of damage to my car.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The City of St. Paul is responsible for keeping the roads of St. Paul (and so this specific road
the pothole was on) in good enough shape and repair so that a vehicle traveling down them does not instantly break and need thousands of dollars’ worth of repairs.
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.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
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: ___________________________
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:
7th St. West and Montreal Avenue
What would you like to see happen to resolve this claim to your satisfaction? Full Payment for Repairs
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 NO
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2007 Make: Nissan Model: Maxima Color: Black
License Plate #: MVY421 State vehicle is registered in: MN
Registered owner of vehicle: Joel Forsberg Driver: Aryana Forsberg
Area(s) damaged: Front Wheel Barrings, Stabilizing Bar Links, Front Bushings, Outer Tie Rod Ends, Spider Knuckles, Front Struts
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: Invoice for repairs - 3 pages
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: Raya Forsberg <
Signature of Person submitting this form: Raya Forsberg
Relationship of person signing to Party making the claim: Sister
Date document is being signed: 5/23/2023
Revised March 2023