Romportl, JoshuaNOTICE 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: ______Josh______________________ Last Name: _________Romportl_____________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, x 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 AJorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: _____1232 Laurel Ave________________________________________________________________________
City: __________St. Paul___________________________ State: ____MN________________ Zip Code: ____55104______________
DayWme/Work Phone: __________________________________ Cell Phone: _______612.412.6379________________________
Date of Incident or Date Discovered (Must Complete): _________05/12/2023_________ Time: __________11:30pm___________
Please state, in detail, what happened that prompted you to file a NoWce of Claim Form: _ran over a pothole and my front right Wre
popped upon impact__
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____The pothole was huge and not safe to
drive on__________
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 submiJed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esWmates for repairs or actual bill that has been paid.
x Automobile damage from a street defect or pothole: please provide two esWmates for repairs or actual bill that has been paid.
$81.96/Wre - new Wre
$20/Wre - Wre installaWon
$9.99 - lugnuts
☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing Wcket (if available), receipt
from Impound Lot, and two esWmates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing Wcket (if available), receipt from Impound Lot, and two esWmates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two esWmates 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.
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, intersecWon or name of city park or facility:
_______IntersecWon near Snelling Ave & Thomas Ave W in St. Paul, MN________________________________________________
What would you like to see happen to resolve this claim to your saWsfacWon?
_______I would like to be reimbursed for my Wres/fees____________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
_____________No_________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s informaWon: Year: _2008__ Make: __Lexus_____ Model: __ES350________ Color: __Black/Charcoal______
License Plate #: ___ASU012_____ State vehicle is registered in: ___MN______________
Registered owner of vehicle: ____Josh Romportl_____ Driver: ____Josh Romportl________________
Area(s) damaged:_____Right Front Passenger 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? ___NA_______________________________________________________________
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? ___NA______ Are you sWll receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
How much Wme have you missed from work? _______NA_______________________________________________________
If you are submiBng other documents, please state what you are aKaching and how many pages: _________________________
Revised March 2023
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.
Name of Person compleWng form: ______Josh Romportl_____________________________________
Signature of Person submiing this form: ______Josh Romportl___________________________________
RelaWonship of person signing to Party making the claim: ______Myself_________________________
Date document is being signed: _______6.16.2023______
Revised March 2023