DiMartini, Sally
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 Sally Last Name DiMartini
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 ____________________________________________________________
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Street Address: 4394 Lily Avenue North_________________________________________________________________________
City: Lake Elmo____________________________________________ State MN __________ Zip Code 55042__________________
Daytime/Work Phone </Cell Phone 651-285-5488____________________________________________
Date of Incident or Date Discovered (Must complete) 3/13/2023Time 11:20 am_________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. When driving I hit a pothole in my lane that was not visible, partially due to the shadow of
the bridge above and the hole. Click or tap here to enter text.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The Pothole was not repaired nor marked as a hazard. It was very deep and nearly impossible
to see. Click or tap here to enter text.
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.< I am attaching 5 photos, one estimate for part replacement and the
actual bill for replacement and repair, which was paid by me.</w
☐ 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? _______________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
Fairview Avenue South,under the bridge, on the southbound 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? __Full reimbursement of the costs I incurred when repairing my vehicle so it is drivable--replacing the
wheel rim and repairing the vehicle’s alignment
Were there witnesses to this incident? Please provide names and contact phone numbers. ____NO__________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year __2021____ Make ____KIA_____________ Model Telluride Color _______BLack_________
License Plate # _________EVR750____________ State vehicle is registered in __MN______________________
Registered owner of vehicle Sally DiMartini____________________ Driver Sally DiMartini________________
Area(s) damaged: Front Passgenger side Wheel Rim was severely bent and needed to be replaced.___________________
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 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. ______________________
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: _Sally DiMartini_______________________________________________ <
Signature of Person submitting this form: Sally DiMartini
Relationship of person signing to Party making the claim: ____self_______________
Date document is being signed 4/4/2023
Revised December 2021