Venning, AlexRevised March 2023
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 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: __Alexander_____________ Last Name: _____Venning___________________________________
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? _________________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ___2219 Eleanor Avenue __________________________________________________________
City: ___St. Paul__ __________________________ State: ___Minnesota__________________ Zip Code: __55116______________
Daytime/Work Phone: __________________________________ Cell Phone: __(804) 512-0514 _____________________________
Date of Incident or Date Discovered (Must Complete): 5/26/2023 Time: _7:45am_______________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _While driving south on Cretin Avenue near
the St. Thomas Campus (about 10 yards north of the intersection with Riverwood Place), I hit a large pothole with my front right tire.
The impact with the pothole was very intense, and my tire pressure indicator light came on immediately afterwards. Within a minute
or two I could hear and feel the flapping of the tire after it went totally flat.__
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __This area of Cretin Avenue has been
plagued by potholes for months. Most potholes have been filled in, but several large potholes remain unfilled. My tire was only a
few months old, having been replaced earlier this year after hitting another pothole on the same road, so it is extremely unlikely
that the tire would have gone flat had it not hit this 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.
Revised March 2023
☐ 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? YES / 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:
Southbound Cretin Avenue north of the Summit Avenue intersection.
What would you like to see happen to resolve this claim to your satisfaction?
I would like for the city to reimburse me for the cost of replacing the tire that was destroyed after impact with this unfilled pothole.
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2011 Make: Hyundai Model: Elantra Color: Silver
License Plate #: 345-WUD State vehicle is registered in: Minnesota
Registered owner of vehicle: Alexander Venning Driver: Alexander Venning
Area(s) damaged: Front Right (Passenger 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? 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: _________________________
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: Alexander Venning
Revised March 2023
Signature of Person submitting this form: Alexander Venning
Relationship of person signing to Party making the claim: Self
Date document is being signed: 5/26/2023