Mohamed, Rahma
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: Rahma Last Name: Mohamed
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? _________________________<
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: _______________________________________________________________________
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Street Address: 13747 Georgia Dr </City: Apple Valley State: <MN Zip Code: </w55124
Cell Phone: 651-508-6913
Date of Incident or Date Discovered (Must Complete): 4/27/23 Time: 10:45 AM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:
My car fell into a pothole, resulting in a popped tire and a dent in the tire plate, which prompted its replacement.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? There was a large pothole in the middle of the road, with no indication that it was there, which
resulted in my car's tire falling inside and popping immediately.
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? 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:
This incident took place on West 7th Street.
What would you like to see happen to resolve this claim to your satisfaction?I would hope that repairs have been made to the road, and I could be reimbursed for the damages to my car.
Were there witnesses to this incident? Please provide names and contact phone numbers: Abdiqadir Mohamed: 651-278-2980
Abdirahman Mohamed: 651-502-5401
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2022 </wMake: HondaModel: Accord </wColor: Black
License Plate #: HDK019State vehicle is registered in: Minnesota
Registered owner of vehicle: Rahma Mohamed Driver: Rahma Mohamed
Area(s) damaged: Tire plate and tire on front driver side.
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: </wRahma Mohamed
Other property damaged: N/A
For injury claims of any type.
What part of your body was injured? No injuries were sustained due to this incident.
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 still receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO <
Employer(s): N/A
How much time have you missed from work? N/A
If you are submitting other documents, please state what you are attaching and how many pages: I will be adding along a picture of the damage and the invoice for the repairs.
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: Rahma Mohamed
Signature of Person submitting this form: Rahma Mohamed
Relationship of person signing to Party making the claim: Myself/ Rahma Mohamed
Date document is being signed: 06/19/2023