Grantier, JosinaNOTICE 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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon
or other relief demanded.”
Please complete this form in its en1rety by clearly typing or prin1ng your answers to each ques1on. If you have addi1onal documenta1on, you may add those
documents to your submission. You will not be contacted by telephone unless clarifica1on is needed. The claim process for inves1ga1ons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sec1ons 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: ________________Josina__________ Last Name: _________________Gran4er______________________
Please Indicate Your Pronouns: x 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? _________________________
Is this claim being made by an AKorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ___________1941 Ford Pkwy #210__________________________________________________________
City: _____________________St. Paul________________ State: ___________MN___________ Zip Code: ________55116________
Day4me/Work Phone: __________________________________ Cell Phone: _______________218-556-1360___________________
Date of Incident or Date Discovered (Must Complete): _____04/06/2023______________ Time: _______________7:25 AM_______
Please state, in detail, what happened that prompted you to file a No4ce of Claim Form: __________________A large pothole
destroyed my front driver’s side 4re beyond repair and it had to be replaced __________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___________The pothole that damaged my
care is on Pelham Ave in St. Paul and has been an issue for an extended period of 4me and has not been fixed________________
Please check the reason that most closely describes the reason for your submiBng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiKed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two es4mates for repairs or actual bill that has been paid.
X Automobile damage from a street defect or pothole: please provide two es4mates 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 4cket (if available), receipt
from Impound Lot, and two es4mates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing 4cket (if available), receipt from Impound Lot, and two es4mates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two es4mates 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.
Revised March 2023
☐ You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
ConEnue to page 2 of NoEce of Claim Form. Failure to complete and return both pages will result in delays.
This secEon must be completed for all claims.
Is there a police report for this incident? YES / 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, intersec4on or name of city park or facility:
_______________Pelham Ave, near the intersec4on of Pelham Ave and Franklin Ave ___________________________
What would you like to see happen to resolve this claim to your sa4sfac4on?
___I would like to be reimbursed for the damage to my car and the potholes on Pelham ave be fixed_______________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
___________No_______________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s informa4on: Year: ___2014___ Make: ____Toyota______ Model: _____Avalon_____ Color: ___Silver___
License Plate #: ______HGv 216___________ State vehicle is registered in: __________Minnesota_____________
Registered owner of vehicle: __Josina Gran4er and Maria Burger______ Driver: ___Josina Gran4er______
Area(s) damaged:____Front drivers side 4re_____________________________________________________________
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 s4ll receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
How much 4me have you missed from work? _____________________________________________________________________
If you are submiBng other documents, please state what you are aKaching and how many pages: __AKaching invoice for the
repair of the car, 2 pages__________
By signing this form, you agree that all informaEon provided is true and correct to the best of your knowledge.
Please NOTE that submiBng a false or misleading claim can and will result in prosecuEon under Minnesota Statutes.
Revised March 2023
Name of Person comple4ng form: ____________Josina Gran4er_________________________________
Signature of Person submigng this form: _______________________________________________________
Rela4onship of person signing to Party making the claim: __________________________________________
Date document is being signed: _____________________
Revised March 2023