Allard, JordanaNOTICE 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 ______Jordana___________ Last Name ______Allard____________________________
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: ___750 Otto Ave. #2104__________________________________
City: _St Paul_______ State _MN____________ Zip Code __55423
Daytime/Work Phone _______________________________ Cell Phone __612-817-9941_____________
Date of Incident or Date Discovered (Must complete) 3/14/2023 Time __9pm__________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _I was driving North/NW on West 7th
close to Montreal. Road crews were working in the left/center lane, so I slowed down to about 15-20 mph in the right lane. As I
approached Montreal, I hit a pothole, which immediately popped my tire. My car sensor went off, indicating the tire had 0
pressure. _
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _Potholes along West 7th in that area have
been getting worse for a long time. I used to drive down Shepard, but those potholes have gotten ridiculous. The pothole I hit was
deep, so it’s been a long time in the making. These potholes should have been filled a while ago.
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.
Traveling North/NW on West 7th, just before Montreal, right lane.
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 reimbursement for my tire__
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 2016_ Make Ford_ Model Edge__ Color __White_____
License Plate # _JVP 494___ State vehicle is registered in __Minnesota
Registered owner of vehicle _Jordana Allard___ Driver _ Jordana Allard _______________
Area(s) damaged _Front, right tire_________________________________________________
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? No__________________________________________________________
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. Photo of pothole, photo of tire
damage, tire replacement receipt (3 items)__
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: __Jordana Allard__
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: ___________________
Date document is being signed 3/22/2023
Revised December 2021