Marrone, Sarah
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 _Sarah_____________________ Last Name _Marrone_____________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐X 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?: _____________________</w:t></w:r></w:p><
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 ____________________________________________________________
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Street Address: _2136 Fry Street, Apt 9______________________________________________________________________
City: _Roseville______________________________________ State _MN__________________ Zip Code __55113____________
Daytime/Work Phone _651-485-7141______________________ Cell Phone _651-485-7141______________________________
Date of Incident or Date Discovered (Must complete) _March 12, 2023____________________Time _8:30pm_______________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _I was driving down Lower Afton Road, towards Highway 61, I passed Battle Creek Road and before
passing Point Douglas Road South, I hit a pothole. My tire was flattened immediately and I pulled over onto Point Douglas Road South. There was another car already stopped on Point Douglas
Road South, he hit the pothole before me and blew out two tires. There were also two cars pulled over on Highway 61 with flat tires and a lost hubcap from hitting the pothole.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? This stretch of Lower Afton Road is notoriously underlit, making it impossible to spot potholes
on the deteriorating road.
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.
X☐ 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 X 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.
_Lower Afton Road, heading towards Highway 61, between Battle Creek Road and Point Douglas Road South
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 the damage caused to my wheel_____
Were there witnesses to this incident? Please provide names and contact phone numbers. _I unfortunately did not get a name, but this gentleman helped me with my tire, skypilot615@gmail.com_____________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2021_____ Make _Honda_______ Model _Civic______________ Color _Black_______________
License Plate # _FWU656____________________ State vehicle is registered in _MN_______________________
Registered owner of vehicle _Sarah Marrone_________________ Driver _Sarah Marrone______________________
Area(s) damaged _Front, passenger-side tire, the wheel/rim was dented rendering it unusable
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________
Other property damaged: _NA__________________________________________________________________________________
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 X No Where? _________________________________________________
Was medical treatment received? Yes X No Where? ______________________________________________________________
First day of medical treatment? _NA____________ Are you still receiving medical treatment? Yes No
Did you miss any work as result of this incident? Yes X No Employer(s) _______________________________________________
How much time have you missed from work?_NA__________________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages. _Invoice for work done on my tire (1 page), proof of payment (1 page), images of damage
to tire (2 pages)_____________________
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: _Sarah Marrone_______________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: ___________________
Date document is being signed March 13, 2023_____________
Revised December 2021