Mukhtar, SabirRevised 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: Sabir Last Name: ____________Mukhtar___ _____
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ____________________Sand Law, PLLC_________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an Attorney? YES If yes, what is your File Number? ____SMukhtar (07451)______________
If yes, provide your Insured’s/ Client’s Name: _________Sabir Mukhtar__________________________
Street Address: ______________273 Selby Ave Apt 202__ _________________________
City: ________St. Paul_________________ State: Minnesota Zip Code: _55102-1843____
Daytime/Work Phone: __________________________________ Cell Phone: _____________+1 (651) 706-5590____________
Date of Incident or Date Discovered (Must Complete): 4/29/2025 Time: 11:36 AM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: Mr. Mukhtar was rear-ended by a City of St.
Paul truck at or near the intersection of West Grand Avenue and Snelling Avenue South in St. Paul, Minnesota, causing Mr. Mukhtar
bodily injury and damage to personal property.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? A state-owned vehicle was at-fault for rear-
ended Mr. Mukhar which resulted in property damage and bodily injury. See also Minnesota State Accident Report.
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.
Revised March 2023
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
If yes, please provide the police report case number: 25071813
If yes, what law enforcement agency responded? _______St. Paul Police Department
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
At the intersection of W Grand Ave and Snelling Ave S
What would you like to see happen to resolve this claim to your satisfaction?
______________Providing our firm with the state insurance information on the vehicle to formally start a liability claim. _____
Were there witnesses to this incident? Please provide names and contact phone numbers: No.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2023 Make: __Mazda__________ Model: ___CX-5________ Color: ___Gray_____
License Plate #: ___JTF114____________ State vehicle is registered in: ____MINNESOTA__________
Registered owner of vehicle: ___CITY OF ST. PAUL_______ Driver: ___Christina Jaworski___________
Area(s) damaged:____Rear end of motor vehicle
If a City vehicle was involved, License Plate #: ___969459_____ Color: ____WHITE____________
Was there City insignia on the vehicle? YES Driver’s Name: Christina
Jaworski_____________________________________________
Other property damaged:
Unknown_______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _Neck and
back____________________________________________________________________________
Did you go to the emergency room or urgent care? YES Where? __Regions
Hospital_________________________________________________
Was medical treatment received? YES Where? _______Regions Hospital___________________
First day of medical treatment? 4/29/2025 Are you still receiving medical treatment? YES
Did you miss any work as result of this incident? NO
Employer(s): _Unknown as to missed work at this time.
________________________________________________________________________________________________
How much time have you missed from work? _Unknown____________________________________________________
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: _Tania Chappell___
Revised March 2023
Signature of Person submitting this form: ____Tania Chappell______
Relationship of person signing to Party making the claim: ___Legal Assistant at Sand Law, PLLC____
Date document is being signed: 5/20/2025