Adams, Margaret
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 ________Margaret_______________ Last Name ___Adams________________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His <☐_ They/ Them/Theirs ☐
Company or Business Name: ____NA__________________________________________________________________________
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 ____________________________________________________________
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Street Address: __452 9th Ave S________________________________________________________________________________
City: South St. Paul State ___MN________________ Zip Code ___55075_______________
Daytime/Work Phone __651-295-6356_____________________ Cell Phone __same______________________________________
Date of Incident or Date Discovered (Must complete) 3/17/2023 Time 5:50 PM_________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. My son was driving on 7th St West going toward 35E, he was right before Albion by the Speedway
gas station, when he hit a pot hole in the right side lane, he pulled into the gas station and found two flat tires on the passenger side of his car. The vehicle that was behind him
also hit the pothole and suffered the same fate. Because my son doesn’t have a lot of money or two spare tires, I had to come to get him, get a tow truck, and have it towed to Discount
Tire near my home.Click or tap here to enter text.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I would argue that the construction signs on the opposite side of the street indicate the City
knew the road needed repair. Therefore, if the City was able to determine the road was bad and put up signs to narrow the lane on the opposite side of the street, they should have known
the other side was bad as well. Since the city does not publish pothole locations reported, there is no way for me to prove they were notified previously of this specific pothole, but
if they are doing construction on that road in the same area, it is reasonable to assume the city knew the road was bad and needed repair. The narrowing of lanes on the opposite side
also promoted more traffic to the side with the pothole, it is reasonable to assume that the City planning folks would inspect both sides of the road and be aware of the stress added
to the open lanes of traffic when one lane is closed or narrowed for construction. My family has been lifelong citizens of Minnesota, and I grew up in St. Paul. I believe my family’s
and my tax dollars entitle me to a reasonable expectation that my son won’t sustain $600 plus damage in my car going to get burgers with his girlfriend on a Friday evening through no
negligence of his own.
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.
7th St W and Albion near the Speedway Gas Station________________________________________________
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? ____financial reimbursement and the pothole fixed. I spent $100 on a tow and another $320 on tires__
Were there witnesses to this incident? Please provide names and contact phone numbers. _Noah Juen 651-706-2840 and his girlfriend Hannah Lauer 651-383-2052_________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2015__ Make Kia_________________ Model _Optima EX___ Color __Red______________
License Plate # _JBE-299____________________ State vehicle is registered in Minnesota________________________
Registered owner of vehicle Margaret Adams__________________ Driver Noah Juen_____________________________
Area(s) damaged __Passenger side tires____________________________________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? No Driver’s Name </w_____________________________________________
Other property damaged: ___________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? __n/a________________________________________________________________________
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? 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. Receipts and picture of tires immediately after hitting the pothole (2 pictures, 2 page
repair bill from Discount Tires.
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: _Margaret Adams_______________________________________________ <
Signature of Person submitting this form: __Margaret M. Adams_______________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/19/2023
Revised December 2021