List, MartinaRevised March 2023
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 this completed form to the Saint Paul City Clerk’s Office by email
(cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”.
Claimant: First Name: ___Martina___________ Last Name: ___List__________
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? YES / NO If yes, what is your Claim/File Number? NO
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? NO
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: 1015 Sperl St
City: West St Paul State: MN Zip Code: 55118
Daytime/Work Phone: 617 513 1988 Cell Phone: 617 513 1988_
Date of Incident or Date Discovered (Must Complete): 2/27/2023 Time: Daytime
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I was driving down Annapolis St in west
side, right by the cross street Livingston, and drove through what I thought was a puddle (this was during the thaw we had…) and hit
a deep pothole that damaged one of the wheels on my car. I didn’t immediately notice the damage, but a couple days later I realized
that the tire was flat. Trying to refill it, I found the dent in the wheel and it wouldn’t hold air properly. Took the car to a tire store and
replaced the wheel. The tire itself wasn’t damaged.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Pothole maintenance/no cones
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.
Revised March 2023
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
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: ___________________________
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:
On Annapolis St, just down from the Livingston intersection
What would you like to see happen to resolve this claim to your satisfaction? Reimbursement for the cost of replacing wheel
Were there witnesses to this incident? Please provide names and contact phone numbers:
No, I was driving alone.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2015 Make: Subaru Model: Impreza WRX Color: Red
License Plate #: GEH 134 State vehicle is registered in: MN
Registered owner of vehicle: Martina List Driver: Martina List
Area(s) damaged: Front passenger side wheel was dented
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? _____________________________________________________________________________
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 the paid bill for
replacing the damaged wheel.
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: Martina List
Signature of Person submitting this form: Martina List
Revised March 2023
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 4/12/2023