Rock, MaggieRevised 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: _Maggie____________________ Last Name: __Rock___________________________________________
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, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ________________879 Juno Ave__________________________________
City: ________Saint Paul_________________________ State: ____MN____________________ Zip Code: _____55102__________
Daytime/Work Phone: ___________same as cell__________ Cell Phone: __(920)366-6180_______________________________
Date of Incident or Date Discovered (Must Complete): 4/7/2023 Time: ___11:40 am_________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __I turned left off Victoria onto Jefferson
Ave. I was driving up the hill and hit a very deep pothole. Proceeded to drive a few feet and my tire pressure indicator came on and
my tired went completely flat (from pothole).__________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __Itis my understanding this was an unfixed
but reported pothole. I acknowledge street infrastructure is a huge issue and this needs, likely, more than a quick fix. However, it
does need that quick fix in the interim. Even as a very aware driver, between the number of potholes and traffic, it can be almost
impossible to avoid. While I was there getting my spare on, 2 other cars had blown tires in the same area. Now, there is an art
installation with all the lost hub caps on Jefferson because it is such an issue and the whole neighborhood knows and yet it’s been
unfixed. __________________________________
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.
Revised March 2023
☐ 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.
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 Jefferson Ave across the street from approximately 956 Jefferson Ave. I had passed 901 Jefferson but there are not buildings for
an address on the side of the street I was on.
What would you like to see happen to resolve this claim to your satisfaction? For this to be resolved to my satisfaction, the City of
Saint Paul would cover the damages to my vehicle in full ($317.92 per invoice)
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: _2021 Make: ___Hyundai________ Model: __Sonata____ Color: ____Black__________
License Plate #: __________FYS-492___________ State vehicle is registered in: ____Minnesota_________________
Registered owner of vehicle: _Hyundai Motor Finance (it is a leased vehicle)_ Driver: ___Maggie Rock___
Area(s) damaged:_Front driver’s side 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? _____________________________________________________________________________
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: __Attaching the invoice/receipt
(1), picture of tire after pothole (1), picture of pothole (1). Three docs/files in addition to claim form._________________
Revised March 2023
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: ___Maggie Rock__________________________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 4/12/2023