Barrett-Gams, Logan
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 _________Logan_______________ Last Name ______Barrett-Gams_______________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His <☐ They/ Them/Theirs ☐
Company or Business Name: ____N/A__________________________________________________________________________
Is this claim being made by an Insurance Company? No If yes, what is your Claim/File Number?: _____</w:t></wN/A______________
Is this claim being made by an Attorney? NO </w:If yes, what is your File Number? ______N/A___________________
If yes, then provide your Insured’s/ Client’s Name _____N/A_______________________________________
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Street Address: _______2115 summit ave_________________________________________________
City: _______St.Paul_______________________ State ___MN__________ Zip Code __55105__________
Daytime/Work Phone ____651-888-1811________________ Cell Phone _____651-888-1811_________
Date of Incident or Date Discovered (Must complete) ______03/11/2023_________Time ____10:15_________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. ___I was driving to my friend's apartment after leaving my dorm at the University of St. Thomas
and started driving towards the freeway on Cleveland Ave N. I hit the pothole a little past Carroll Ave (Will provide pictures of the pothole). I then made my way to the freeway I-94
West. After being on the freeway for a couple of seconds I realized my car was pulling to the right and saw my PSI dropping on the gauge indicating the front passenger tire had gone
flat. I called USAA and other services to help get it changed but they all canceled. I then had to wait almost 3 hours before someone walking by was able to help change the tire with
his own equipment. On Sunday I brought it in to see if the tire was repairable and it was not. On Monday the 13th, I found out that they stopped making my exact tire model and had to
replace all 4 tires at a high cost at discount tire in St.Paul.__________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __It is my belief that the city has a responsibility to maintain safe roads for drivers, as potholes
present a significant hazard to vehicular traffic and can cause extensive damage to vehicles. Prompt repair and maintenance of such potholes are essential to ensure driver safety. Furthermore,
it is my contention that the city should be held accountable for any damages incurred due to its failure to adequately maintain and repair potholes. The existence of deep potholes that
have persisted for months on many roads near St. Thomas highlights the necessity for the city to implement sufficient measures to ensure the safety of its roads. In light of these concerns,
it is my view that the city should be held liable for any damages resulting from its failure to fulfill its responsibility to maintain safe roads for drivers.__________
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? Yes No If yes, please provide the police report case number _______N/A___________
Revised December 2021
If yes, what law enforcement agency responded? __________N/A___________________________________________
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
________Cleveland Ave N near Carroll Ave. Just past the Lucy apartments and Gas station on the corner___________________________
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? ______Reimbursment & Pothole filled_____________
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 _2013___ Make ___Lexus_______ Model ____GS 350______ Color ___Black____
License Plate # _____AZD-392_________ State vehicle is registered in _____Minnesota___________
Registered owner of vehicle ____Kathleen Gams__________ Driver ____Logan Barrett-Gams__________________
Area(s) damaged ______Front passenger wheel_____________________________________________________
If a City vehicle was involved: License Plate # ___________N/A____________________ Color _______N/A_____________________
Was there City insignia on the vehicle? 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? _____NO_________________________________________________________
Did you go to the emergency room or urgent care? Yes No Where? ____N/A_____________________________________________
Was medical treatment received? Yes No Where? _________N/A____________________________________________________
First day of medical treatment? ___N/A_______ Are you still receiving medical treatment? Yes No
Did you miss any work as result of this incident? Yes No Employer(s) __________N/A_______________________________
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. ____(4 extra pages) Picture of pothole and receipt from discount tire ( Had to get all
new tires as they stopped making my exact tire ).______________
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: ____Logan Barrett-Gams____________________
Signature of Person submitting this form: _____Logan Barrett-Gams______________________________________
Relationship of person signing to Party making the claim: __Myself___________
Date document is being signed _03/13/2023_____
Revised December 2021