Schaber, JaclynNOTICE 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 _Jaclyn __________________________ Last Name Schaber______________________________________
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: 766 County Road F, Unit A_________________________________________________________________
City: Shoreview State MN__________________ Zip Code 55126_______________
Daytime/Work Phone _651-253-7916________________________ Cell Phone 651-253-7916________________________________
Date of Incident or Date Discovered (Must complete) 2/28/2023 Time _8:30pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. There was a large pothole driving East on
W. Seventh St in the right-hand lane between the streets of Madison and Rankin that could not be seen due to the road not being
well lit at that time of day and thus it could not be avoided. This caused my right rear passenger tire to go flat shortly thereafter
along with cracking the rim resulting in them both needing to be replaced. Additionally, the right front passenger tie rod was also
damaged from the pothole and had to be replaced. Due to the time of day of the incident and where the tire failed (35E North, mile
marker 105) my vehicle had to be towed for repairs and I had to call a family member for a ride.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Road clearly not maintained and in driving
condition for motorists_________________
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.
Driving East on W. Seventh St in the right-hand lane between the streets of Madison and Rankin.
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? _Vehicle damages covered______________________
Were there witnesses to this incident? Please provide names and contact phone numbers. _No_____________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2011_____ Make Ford____________ Model __Fusion_________ Color Bordeaux_______________
License Plate # _AYB 238____________________ State vehicle is registered in __MN______________________
Registered owner of vehicle Jaclyn Schaber_____________________ Driver __Jaclyn Schaber________________________
Area(s) damaged _Rear passenger tire and rim. Along with front passenger tie rod.________________________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________
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. _Repair bill with charges from
this incident highlighted. 1 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: Jaclyn Schaber________________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/14/2023
Revised December 2021