Lopez, Salvador
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 is to the Saint Paul
https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may <
mailto:cityclerk@ci.stpaul.mn.usemail, 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 Salvador_______ Last Name Lopez_______
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? </w:t </w:t></w:r If yes, what is your Claim/File <Number?: _____________________
Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
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Street Address: 1375 Davern St Apt 337__________________________
City: Saint Paul State MN Zip Code 55116
Daytime/Work Phone 612-481-2928 Cell Phone 612-481-2928_
Date of Incident or Date Discovered (Must complete) 3/3/2023Time _________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. __I was driving northbound on Snelling Ave and could not avoid the potholes between Claire
Avenue and Fairmount Ave. After hitting a deep pothole my rear right tire popped and rim cracked. ___________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___due to the large number of pothole taking up most of the right lane on that part of Snelling
Ave the city should have made that a priority to fill, especially with holes that are so deep to cause such damage as mine took.___________________________
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.
__Snelling Ave, between Claire Ave and Fairmount Ave.___________________________________________________
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 would like to be reimbursed for my damaged rim and tire replacement fee, also ask to have someone look
over the potholes in that area to note the importance to get those filled._________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. ____None__________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year __2008____ Make BMW Model 335xi Color Black
License Plate # NXK304 State vehicle is registered in MN
Registered owner of vehicle Josie Gonzales Driver Salvador Lopez
Area(s) damaged Rear Right Tire
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name </w_____________________________________________
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. ______2 photos of the potholes that caused the incident and a scanned copy of the receipt
for the Rim replacement and fees of tire replacement.________________
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: ___Salvador Lopez_____________________________________________ <
Signature of Person submitting this form: Salvador Lopez
Relationship of person signing to Party making the claim: ___________________
Date document is being signed 3/8/2023
Revised December 2021