Desmond, DanNOTICE 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 __Daniel__________________________ Last Name ____Desmond__________________________________
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 Name ____________________________________________________________
Street Address: _1460 Saint Albans St N___________________________________________________________________________
City: ____Saint Paul_____________________________________ State ______MN___________ Zip Code ___55117__________
Daytime/Work Phone ____651-357-8322__________________ Cell Phone ____651-357-8322___________________
Date of Incident or Date Discovered (Must complete) 7/31/2022 Time ___6 pm______________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. __I was driving west on Hoyt Avenue W (turning west from Grotto St N) and hit a large pothole
in the middle of the street. I immediately heard a change in how my car sounded and took it into a shop the following weekend. According to the shop (see attached invoice) both of my
rear coil springs/suspension were broken and needed to be replaced. ___________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _If the pothole had been filled in earlier, I would not have sustained the damage to my vehicle.
_____________________________
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.
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.
___Hoyt Ave W & Grotto St N, Saint Paul, MN______________________________________________________________________
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? _As of this writing (9/26/22) it appears the pothole has been filled in, so I would like compensation for
the damages. ____________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. ____No other witnesses___________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2009__ Make _Volkswagen_______ Model ____GTI________________ Color __Gray__________
License Plate # __HUM700___________________ State vehicle is registered in ___Minnesota_____________________
Registered owner of vehicle _Daniel Desmond_________________ Driver _Daniel Desmond_________________
Area(s) damaged __Suspension coil springs, rear (both)_______________________________________________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________
Other property damaged: __N/A_________________________________________________________________________________
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. _One image (one page) of invoice paid_____________________
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: __Daniel Desmond______________________________________________
Signature of Person submitting this form: __Daniel Desmond_________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 9/26/2022
Revised December 2021