Clarey, Molly
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 _Molly_______________________ Last Name __Clarey________________________________________
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? 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: __610 Summit Ave. #208_________________________________________________________________________
City: __Saint Paul__________________________________________ State _MN_______________ Zip Code _55102_____________
Daytime/Work Phone _262-313-7353_______________________ Cell Phone ____________________________________________
Date of Incident or Date Discovered (Must complete) 2/25/2023 </wTime _3:30 PM________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was forced to pay $227 for a new tire because of driving over a large, unavoidable pothole
on Summit Avenue. This pothole had been present on the street for multiple days.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _This pothole is massively large, had been present on a thoroughfare for multiple days. The pothole
was located in east-bound land and was unavoidable due to parked cars on the south-side of the street and incoming traffic to the north. I would not have to spend money on a new tire
had the pothole been repaired in a timely manner by the City of Saint Paul.
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.
____598 Summit Avenue Saint Paul, MN 55102 _________________________________________________________________
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? _Reimburse me for lost funds due to tire repair_
Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2012___ Make _Ford____________ Model _Focus_______________ Color _Red____________
License Plate # _____________________ State vehicle is registered in _MN_______________________
Registered owner of vehicle __Molly Clarey___________________ Driver __Molly Clarey __________________________
Area(s) damaged _Driver’s side front 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? _NO_________________________________________________________________________
Did you go to the emergency room or urgent care? NO Where? _________________________________________________
Was medical treatment received? 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? 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. _3 pictures and photo of service bill are attached to the following page.
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: ___Molly Clarey___________________________________________ <
Signature of Person submitting this form: __Molly Clarey___________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/10/2023
Photo of bill for new tire provided by Bobby and Steve’s.
Tire immediately starting to deflate.
Size comparison of pothole
Location of pothole in street: