Martinez, AbiudeliakimNOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota
Minnesota State Statute466.05 states that “…every person…whoclaims damages from any municipality…shallcause to be presented tothe governing body of the
municipalitywithin180days after the allegedlossor injury is discovered a notice stating thetime,place,and circumstancesthereof,and the amount ofcompensation
orother relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question.If youhave additionaldocumentation you may addthose
documentsto your submission.You will not be contacted bytelephone unless clarification is needed.Theclaim process for investigations can take upwardsof
four(4)weeks.This form mustbesigned,dated with all applicable sections completed.Submission isto the Saint Paul City Clerk’s Office.You may email,fax
(651-266-8574)or mail the form.Mailing address is “SaintPaul City Clerk,15 WestKelloggBlvd.,Suite310,Saint Paul,MN 55102”
Individuals:First Name __Abiudeliakim_____________Last Name _________Martinez____________________________________
Please Indicate Your Pronouns:She/Her/Hers ______He/Him/His _he_____They/Them/Theirs _______
Company or Business Name:_____none_________________________________________________________________________
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,then provide your Insured’s/Client’s Name ____none________________________________________________________
Street Address:__492 Central W _______________________________________________________________
City:____St.paul______________________State _____Minnesota__________________Zip Code ____55103______________
Daytime/Work Phone __6513360874_________________Cell Phone ___6513369874_____________________________
Date of Incident or Date Discovered (Must complete)______4/11/23______________Time _____9:25 pm____________________
Please state,in detail,what happened that prompted you to file a Notice of Claim Form.____A pothole damaged my front
alignment and caused my steering-wheel to be crooked when aligned with my tires.________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages?_____This was an unexpected incident and
expense that could have been prevented if the city cared enough to cover it up_________________________
______________________________________________________________________________________________________
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.
_$123.00-$155.00__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.
This section 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 ____no________________
Revised December 2021
Notice of Claim Form,page two.Failure to complete and return both pages will result in delays.
If yes,what law enforcement agency responded?___no____________________________________________________
Where did the incident take place?Please provide a street address,intersection or name of City park or facility.
___concordia street,in between marion street and western
ave._______________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?______I would be be more than happy and relieved if I
was compensated money to fix the damage the pothole caused.___________________________________
________________________________________________________________________________________________________
Were there witnesses to this incident?Please provide names and contact phone numbers._____Marybell Martinez
651-341-0242_________________________
________________________________________________________________________________________________________
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year _2016_______Make ______Dodge ___________Model _____Journey_______________Color
____Black____________
License Plate #____FJG 348_________________State vehicle is registered in ____Minnesota____________________
Registered owner of vehicle ___Yeni Martinez________Driver __Abiudeliakim Martinez_________
Area(s)damaged _____wheel
alignment______________________________________________________________________________
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.__I will be submitting photos of
the pothole and what damage it caused to my vehicle.____________________
_______________________________________________________________________________________________________
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:___Abiudeliakim Martinez_____________________________________________
Relationship of person signing to Party making the claim:_________________________________________________________
Date document is being signed ________________________
Signature of Person submitting this form:
Revised
December 2021