Schulz, MadelineNOTICE 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: Madeline Last Name: Schulz Please Indicate Your Pronouns: She/Her/Hers
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 AEorney? YES / NO If yes, what is your File Number? _______________________________________
Street Address: 2427 3rd Ave S APT B17 City: Minneapolis State: MN Zip Code: 55404 Cell Phone: 608-212-3213
Date of Incident or Date Discovered (Must Complete): April 28, 2023 Time: 3:30 AM
Please state, in detail, what happened that prompted you to file a NoNce of Claim Form: En route to MSP airport, driving south on
Hwy 5/W Seventh St, inside (leT) lane. Low visibility due to lighXng condiXons (night), distances between street lights and wet
pavement from recent (light) rain. Somewhere between S Homer St & S Madison St, I hit the unseen pothole with the front wheel
(drivers-side), which caused the vehicle to jolt down with an audible thud, and triggered the Xre pressure gauge as the Xre
immediately lost air. Upon my own and AAA’s tow inspecXon, there is direct damage to the rim of the wheel in the form of a
visible dent on the inside of the rim in addiXon to the deflated Xre.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Hwy 5 is a direct and highly traveled route
from Saint Paul to MSP Airport. The outside lanes of the Hwy 5/W Seventh St strip are covered in potholes that are easily seen
during the day, and unfortunately I was driving in dark (night) condiXons. Assuming that other noXces and damage claims have
been made for this secXon of Hwy 5 prior to this report, I demand to be compensated for the cost of parts, labor and repairs to
restore the damages that were sustained by my property on Hwy 5/West Seventh Street, especially since its care and upkeep is an
acXve project for MnDOT.
Please check the reason that most closely describes the reason for your submiang a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiEed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esNmates for repairs or actual bill that has been paid.
X Automobile damage from a street defect or pothole: please provide two esXmates 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 Ncket (if available), receipt
from Impound Lot, and two esNmates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing Ncket (if available), receipt from Impound Lot, and two esNmates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two esNmates 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.
Revised March 2023
ConXnue to page 2 of NoXce of Claim Form. Failure to complete and return both pages will result in delays.
This secXon 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, intersecNon or name of city park or facility:
Hwy 5/W Seventh St, between S Homer St & S Madison St.
What would you like to see happen to resolve this claim to your saNsfacNon?
Full compensaXon for the cost of repairs to restore the damages that were sustained by my vehicle ($1282.54).
Were there witnesses to this incident? Please provide names and contact phone numbers:
Lauren Twite, witness/passenger. Phone: 1 (218) 750-4602
For property damage claims, including vehicle accidents.
Your vehicle’s informaNon: Year: 2017 Make: Mazda Model: Mazda 3 Color: Red
License Plate #: AJH6059 State vehicle is registered in: Wisconsin
Registered owner of vehicle: Gary McKenzie (father) Driver: Madeline Schulz (daughter)
Area(s) damaged: Front Wheel/Rim/Tire (drivers-side)
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? Not Applicable
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 sNll receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
How much Nme have you missed from work? _____________________________________________________________________
If you are submiang other documents, please state what you are agaching and how many pages: (2) Images of damage to Xre,
wheel and rim. See page 3-4 of Claim Form. Bill from repairs. See page 5-6 of Claim Form.
By signing this form, you agree that all informaXon provided is true and correct to the best of your knowledge.
Please NOTE that submiang a false or misleading claim can and will result in prosecuXon under Minnesota Statutes.
Revised March 2023
Name of Person compleNng form: Madeline Schulz
Signature of Person submiXng this form: _______________________________________________________
RelaNonship of person signing to Party making the claim: N/A
Date document is being signed: 5/5/2023
AddiXonal Documents:
Image 1, Damage to front (driver-side) Nre from the outside.
Revised March 2023
Image 2, Damage to front (driver-side) rim from the inside.
Revised March 2023