Wagner, MatthewRevised 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: Matthew_________________ Last Name: Wagner_______________________________________________
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: 1402 Larpenteur Ave. W_________________________________________________________________________
City: Falcon Heights______________________________ State: __MN__________________ Zip Code: __55113_________________
Daytime/Work Phone: __________________________________ Cell Phone: __651-366-1424
___________________________________________
Date of Incident or Date Discovered (Must Complete): 3/26/2023 Time: ______9:05pm_______________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ____I was driving home with my daughter
from rehearsal practice at the O’Shaughnessy Theater, north on Cleveland Ave, and struck a devastating pothole between Iglehart &
Carroll, causing my tire to burst on the front passenger side. It also bent my rim. I had to get my car towed, a new tire put on, and
the rim straightened.________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ______It was a very large pothole, right in
the road where someone driving appropriately in the lane, would likely drive directly over it with their front, passenger wheel. It was
dark and I hadn’t driven on Cleveland in some time so I was unaware and couldn’t see it until it was too late. Additionally, had I
known it was there, I would have had to either swerve left into oncoming traffic or right into the bike lane, thus leaving the safety of
the driving lane.______________________________
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:
_______________________Cleveland Ave, heading north i.e. eastern side, between Iglehart Ave & Carroll Ave
_____________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
______________I would like to have some or all of my $318 in repairs compensated please. I have AAA so I used my once per year
allowance of a Free Tow to tow it to the repair shop. Seems inappropriate to attempt to charge the City of St Paul for that.
______________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
_____My daughter Olivia Wagner was the only actual witness. She is 8-years old and the phone number would be the same as mine.
_____________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ______2007___ Make: ____Mazda_____________ Model: ______3____________ Color: Green
__________________
License Plate #: ______CVA278___________________ State vehicle is registered in: ___MN________________________
Registered owner of vehicle: ______Matthew Wagner_______ Driver: Matthew Wagner__
________________________________________
Area(s) damaged:________Front right passenger side wheel & 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): _________________________________________________________________________________________________
Revised March 2023
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: ___Matthew Wagner__________________________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed: 4/14/2023