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: Janeijha Last Name: Jones
Please Indicate Your Pronouns: She/ Her/Hers x 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 Choose an item.If yes, what is your File Number?
_______________________________
If yes, then provide your Insured’s/ Client ’s Name ____________________________________________________________
Street Address: 400 Luella st
City: Saint Paul State: MN Zip Code: 55119
Daytime/Work Phone: (651) 225- 9177 Cell Phone: (651) 336-5457
Date of Incident or Date Discovered (Must complete) Thursday, April 14th 2022 Time: 4:13pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:
I was driving on Old Hudson road and Ruth street with my mother and younger sister. I went to make a right turn and in doing so I hit
a big deep pothole that I could not see when making the turn and It popped the tire and messed up the rim on the car rental that I
had at the time.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
I feel the city is responsible because It ’s a pothole that has been missed. You can tell from the roads that the city has filled potholes
on the same road. However, it seems as if they missed this pothole or they just skipped it and from the depth/size of this pothole. It
shouldn't have been missed in the first place.
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.
X Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid.
Estimate/Total damage cost: $591.23
☐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, there is not
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.
Old hudson road and Ruth street intersection
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? Reimbursement or pay for rental repairs
Were there witnesses to this incident? Please provide names and contact phone numbers:
Cellastine Washington # (612) 990- 8152 or (612) 274- 4877
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2021 Make: Toyota Model: Camry SE Color: White
License Plate #: State vehicle is registered in: Florida
Registered owner of vehicle: Enterprise Driver: Janeijha Jones
Area(s) damaged: Front right passenger Tire and Rim
If a City vehicle was involved: License Plate #: N/A Color: N/A
Was there City insignia on the vehicle? N/A Yes No
Driver ’s Name: N/A
Other property damaged: N/A
For injury claims of any type.
What part of your body was injured? N/A__________________________________________________________________________
Did you go to the emergency room or urgent care? No Where? _________________________________________________
Was medical treatment received? No
Where? ______________________________________________________________
First day of medical treatment? N/A
Are you still receiving medical treatment? No
Did you miss any work as result of this incident? No Employer(s) _______________________________________________
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: Picture of the intersection (1
pic), Pictures of the Tire (2 pic) Rim (2 pic), Pothole (2-3 pic) and Price estimate from enterprise.
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: Ja’Neijha Jones
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: ___________________
Date document is being signed _____________
Revised December 2021