O'Halloran, Mary
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: Mary Last Name: O’Halloran
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 ____________________________________________________________
Street Address: 394 Pierce Street
City: Saint Paul State: MN </w:t></w:r><w:r><w:rPr><w:sz Zip Code: 55104
Daytime/Work Phone: 651.646.7871 < Cell Phone: < 651.216.8703
Date of Incident or Date Discovered (Must complete): 1/20/2023 Time Citation Written 1:49am Vehicle went into impound 3:28am
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. </I went to an Urgency Room on Thursday January 19, 2023 for an extremely painful right foot
and rash on heel of left foot. During the time I was there I checked the St. Paul Snow Emergency Map 4 times, each time it showed, ‘NO SNOW EMERGENCY NORMAL PARKING’. When I arrived
home after stopping to pick up 3 prescriptions given by UR Doctor, at 10pm, I noticed cars parked on night plow side of the street which lead me to believe it was ok to park on the side
of the street, but wanting to be sure I opened the St. Paul Snow Emergency Map for the 5th time that day. I entered my address and zoomed in on my street. The map showed, ‘NO SNOW EMERGENCY
NORMAL PARKING’ yet again and so I proceeded to hobble up to the apartment bldg. main entrance door. When I left for work the following morning to my surprise my car was not where I
had parked it. I immediately thought it had been stolen, I called my boss to them know this and they asked if I sure it had been stolen and not impounded. I was addiment that it was
stolen, because I checked the St. Paul Snow Emergency Map and it showed no snow emergency normal parking. After calling my work I was going to report vehicle stolen, then I thought,
that before I call my insurance company and the police to report it stolen, maybe I should call police impound and in doing so found out that they did have my vehicle. When I asked why
the towed it when the snow emergency map showed no snow emergency/normal parking for my street at 10pm that night. The police impound dispatcher said they do not go by the map, that
the snow emergency was posted at 1pm and was on the news and all over social media. Although since I was in the Urgency Room I did not watch the news and did not go on any social media
sites, I DID check the ST. PAUL SNOW EMERGENCY MAP, I questioned why such a map exists if the city doesn’t go by it. They did not have an answer for me, when I finally obtained a ride
to around 3pm to go get my vehicle that day, I notice at least 3 postings on the walls of the police impound lot lobby for the St. Paul Snow Emergency map.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The reason I feel I should be reimbursed the towing fees is not only because the St. Paul/Snow
Emergency Map showed ‘NO SNOW EMERGENCY/NORMAL PARK after I enter my exact street address, but also because they never even plowed my street that day, the night before, the next day
or the day after that or the day after that. The next time the street was plowed was when we received the record-breaking snow fall on February 22, 2023. Which the plow truck went around
all the vehicles on my block and surrounding blocks around my block, as well as on the storm prior to this on January 4, 2023. I have and do always abide by snow emergency parking rules
and would have never parked on the street that night had the map not showed that it was alright to do so._____________________________
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. This is a request
for reimbursement of towing fees.
☐ 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 </w:tIf yes, please provide the police report case number ____________________
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:
394 Pierce Street, Saint Paul, MN 55104 ________________________________________________________________________
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 towing fees and if possible for the full day of work I missed due
to having my vehicle towed and impounded____________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. Dave Tester Phone # 651.515.5696
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year ______ Make _________________ Model ____________________ Color ________________
License Plate # _____________________ State vehicle is registered in ________________________
Registered owner of vehicle ______________________________ Driver ______________________________________
Area(s) damaged ___________________________________________________________________________________
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 </w:t></w:r><wEmployer(s) Keys Well Drilling Company
How much time have you missed from work? 1 Day
If you are submitting other documents, please state what you are attaching and how many pages. Six (6) attached photos of plowed around vehicles from Feb 22nd, Three (3) attached photos
of Pierce Street never plowed from Jan 20th to 24th, One (1) attached document of Impound Lot receipt and Two (2) attached photos of Snow Emergency Map on walls in police impound lobby.
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: Mary O’Halloran_____________________________________________________________ <
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/15/2023
Revised December 2021