Dyer, NickNOTICE 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: ______Nick ____________________ Last Name: __________DYER_____________________________
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 ALorney? YES / NO If yes, what is your File Number? _______NO___________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ________2015 Wellesley Ave_____________________________________________________________________
City: ____St Paul ________________________________ State: ____________MN__________ Zip Code: _____55105_________
DayVme/Work Phone: __________________________________ Cell Phone: ____6512496342_____________________________
Date of Incident or Date Discovered (Must Complete): __4/5/23___________________ Time: ______9:30 pm ______________
Please state, in detail, what happened that prompted you to file a NoVce of Claim Form: _____The roads all around my
neighborhood have been completely ignored to the city of st Paul repair crews. For weeks giant pot holes have been le_ unaLended
to. I called to report these potholes (along Randolph and Fairview and also on St. Clair and Prior.) These are incredibly dangerous as
people are swerving around them, someVmes into oncoming traffic. My vehicle hit many of these potholes over the months of
March and April. A_er hiang one I could hear a loud raLle coming from underneath the vehicle as something became dislodged and
was dragging. Then on April 5 I hit a pothole (that had been there for weeks!) And my wheels started to give a nasty clicking sound. I
then got a quote to fix the problem and it was over $3,000 to fix the U joints and axles of the vehicle!!
_____________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? These potholes went unfixed for over two
months! I watched and saw no aLempt to fix these potholes. The city is not only responsible but negligent in the one of the main
things you are supposed to do, maintain roads and bridges. I pay taxes. But the roads and schools are embarrassing. Fix this problem!
I know others my age (early 40s) are also thinking about geang out and moving to Texas or Florida where at least inept governments
don’t ask for more money to be inept.
Please check the reason that most closely describes the reason for your submiDng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiLed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esVmates for repairs or actual bill that has been paid.
X Automobile damage from a street defect or pothole: please provide two esVmates 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 Vcket (if available), receipt
from Impound Lot, and two esVmates for repairs or actual bill that has been paid.
Revised March 2023
☐ Snow Emergency: please provide copy of towing Vcket (if available), receipt from Impound Lot, and two esVmates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two esVmates 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.
ConGnue to page 2 of NoGce of Claim Form. Failure to complete and return both pages will result in delays.
This secGon must be completed for all claims.
Is there a police report for this incident? YES / NO 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, intersecVon or name of city park or facility:
_______St. Clair and Prior. Also Randolph and
Fairview_____________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your saVsfacVon?
___________________________________________________________________I would like the city to reimburse me for the
damage caused to my vehicle: $4585.14 ______________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________Rita Black 6122093689, Maria Dyer 6512027358, Joan Dyer
6514835646, Thomas Dyer 6512496342______________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s informaVon: Year: _2000________ Make: ___Jeep______________ Model: ___Wrangler_______________ Color:
__Blue________________
License Plate #: ___951VTB______________________ State vehicle is registered in: ___MN________________________
Registered owner of vehicle: ____Nick Dyer_______________ Driver: _____NICK
DYER___________________________________
Area(s) damaged:________________Wheels and Axels ___________________________________________________
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? ________________________________________________________________
Revised March 2023
First day of medical treatment? _____________ Are you sVll receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
How much Vme have you missed from work? _____________________________________________________________________
If you are submiDng other documents, please state what you are aQaching and how many pages: _______3__________________
By signing this form, you agree that all informaGon provided is true and correct to the best of your knowledge.
Please NOTE that submiDng a false or misleading claim can and will result in prosecuGon under Minnesota Statutes.
Name of Person compleVng form: ___Nick Dyer__________________________________________________________
Signature of Person submiang this form: _______________________________________________________
RelaVonship of person signing to Party making the claim: __________________________________________
Date document is being signed: ___4/24/2023__________________
Revised March 2023