Fillable Notice of Claim formNOTICE 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 is to the Saint Paul City Clerk’s Office. You may email, fax
(651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”
Individuals: First Name _Hiawatha___________________________ Last Name Smith
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? NO If yes, what is your Claim/File Number?: _____________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s N ame ____________________________________________________________
Street Address: ____500 E Grant St Unit 1311 ____________________________________________
City: _____Minneapolis___________________________________ State ________MN_______ Zip Code ____55404_________
Daytime/Work Phone _______________________________ Cell Phone ____336-254-2093________________________________
Date of Incident or Date Discovered (Must complete) 4/5/2022Time ______2:49pm___________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. ___I was driving down Summit Ave
heading east from Dale St toward Summit Overlook Park. As I was driving approaching the light at Ramsey, my car hit a major
pothole/cave-in and the front tire immediately popped. Then subsequently the rear tire immediately started to loose air as that tire
was punctured as well due to the pothole. __________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ________This was a pothole/cave-in on a
major/busy street of Saint Paul. The pot hole couldn’t be easily avoided and it was clearly raining during this time. The pothole
caused the damage to both my driver side front and rear tires. With this major impact, the vehicle had to be towed to get the repairs
done. As the damage was bad enough to permanently damage two tires, I was also required to get an alignment. This was not any
negligence on my part as I was just driving and the irregular pothole ruined two of my tires. ______________________
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 pai d.
☐ 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.
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 ____________________
Revised December 2021
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.
___On Summit ave between Arundel and Ramsey Streets headed towards I94. This i s near Summit Overlook
Park.______________________________________________________________________
Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your satisfaction? ________I should be reimbursed as this was major
damage done to my car that was an expensive out of pocket cost that I literally cannot afford. This street damage had to have been
there for a while and should have been repaired by t he city as it as you see from my damage can cause damage to vehicles.
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 _2017_____ Make Honda Model Accord Color Red
License Plate # ______T3138_______________ State vehicle is registered in _______NC_________________
Registered owner of vehicle _____Hiawatha Smith_________________________ Driver Hiawatha Smith
Area(s) damaged ______Front and Rear Driver-Side Tires, Alignment
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. ___Attachments include:
Pictures of the tire damage, proof of payment for the tire replacement and alignment, proof of payment for the tow, pictures of the
pot hole from different angles. ___________________
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: _______Hiawatha Smith_________________________________________
Signature of Person submitting this form: ___________Hiawatha D Smith________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 4/6/2022
Revised December 2021