Hartman, Katrina
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 Katrina Last Name Hartman
Please Indicate Your Pronouns: She/ Her/Hers ☒ He/Him/His <☐_ They/ Them/Theirs ☐
Company or Business Name: _____N/A_________________________________________________________________________
Is this claim being made by an Insurance Company? </w:t </No </w:t></ If yes, what is your Claim/File <Number?: _______N/A__________
Is this claim being made by an Attorney? NO If yes, what is your File Number? ___N/A____________________________
If yes, then provide your Insured’s/ Client’s Name ______N/A______________________________________________________
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Street Address: ___________2289 Hillside Ave___________________________________________________________________
City: ________St. Paul__________________________ State ___MN________________ Zip Code ____55108______________
Daytime/Work Phone _______N/A________________________ Cell Phone ____651-815-3293____________________________
Date of Incident or Date Discovered (Must complete) 4/1/2023 </Time _______8:25PM__________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _________I was driving my vehicle and encountered several large potholes which I was unable
to swerve around for safety reasons and drove through. I noticed my vehicle immediately started “pulling” towards the right and didn’t feel right, so I pulled over about 45 seconds later
(when it was a safe spot to do so) and saw that my right front tire was flat. I then called AAA for a tow.____________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____There were numerous very large, deep potholes in a high traffic intersection that you cannot
swerve around for safety reasons. This was extremely dangerous and caused damage to my car which was previously in perfect condition (less than a week ago I got 4 brand new tires, breaks,
and had an alignment done and followed up with the 25 mile safety check).__________________________
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 _____N/A_____________
Revised December 2021
If yes, what law enforcement agency responded? __________N/A_____________________________________________
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
____________________The intersection of Eustis St/Dave Ray Ave/Franklin Ave__________________________________
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 compensated for the tire labor from these numerous coalesced potholes. I used
one of my AAA tows, borrowed my roommates car, and my tires were covered under warranty since I just purchased them less than a week ago, so I just had to pay labor costs to put the
new tire on, however this still took a large amount of time/hassle to deal with which is why I am filing this claim so this hopefully does not happen to anyone else.________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. __Yes, Austin Greenwalt, 952-484-3579
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year __2013____ Make ___Volkswagen______ Model ___Jetta_____ Color __Gold_________
License Plate # ___EPJ249____________ State vehicle is registered in ______MN______________
Registered owner of vehicle ____Katrina Hartman______ Driver ____Katrina Hartman______________________
Area(s) damaged _______Right front tire ______________________________________________
If a City vehicle was involved: License Plate # _______N/A________________________ Color ____N/A_____________________
Was there City insignia on the vehicle? NO Driver’s Name </w___N/A______________________________________
Other property damaged: _________________N/A______________________________________________________________
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? _________N/A________________________________________
Was medical treatment received? NO Where? </___________N/A________________________________________________
First day of medical treatment? ___N/A________ Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? NO Employer(s) <________N/A_____________________________________
How much time have you missed from work?________N/A_________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages. ____Attaching photos of potholes and the street sign. Also attaching photo of receipt from
auto shop to put on the new tire.__________________
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: ___________Katrina Hartman________________________________ <
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 4/2/2023
Revised December 2021