Notice of Claim Form - Fillable - 2023_0
NOTICE 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
after the alleged loss or injury is discovered a notice stating the time, place, and circumstances thereof, and the amount of compensation or other relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question. If you have additional documentation, you may add those documents to your submission.
You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks. This form must be signed, dated with
all applicable sections completed. Submission this completed form to the
mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint 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: Merrit Last Name: Stoltzman
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? 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, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: 2338 Marshall Ave
City: Saint Paul State: MN Zip Code: 55104
Daytime/Work Phone: 507-720-2078 Cell Phone: 507-720-2078
Date of Incident or Date Discovered (Must Complete): 8/16/2023 Time: 4:40PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: On August 16th, 2023 at approximately 4:40PM, I was driving my Ford Fusion in downtown St. Paul
when I hit a very large pothole and my front driver side tire popped and went completely flat. I was driving east bound on Fifth St. W and taking a right hand turn onto Seventh St. W
when I hit the pothole. I had to purchase and replace my tire and receive an alignment to repair the damages.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I was driving on City of Saint Paul roads that were not properly maintained. The pothole is not
visible as it is located on the turn, and it is a tight turn with no room to avoid the pothole.
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.
☒ 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.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
This section must be completed for all claims.
Is there a police report for this incident? 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, intersection or name of city park or facility:
East bound on Fifth St. W, taking a right hand turn onto Seventh St. in the city of Saint Paul.
What would you like to see happen to resolve this claim to your satisfaction? I would like to be compensated for the cost of the one tire that was replaced ($245.95) and the wheel alignment
($99.95). ____________________________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 Mackenzie Stradtmann-
612-388-9709, William Walz- 612-978-5328
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2013 Make: Ford Model: Fusion Color: Black
License Plate #: FTA783 State vehicle is registered in: Minnesota
Registered owner of vehicle: Matthew Stoltzman Driver: Merrit Stoltzman
Area(s) damaged: Front driver side tire, and vehicle alignment
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? YES / NO Driver’s Name</w: ______________________________________________________
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: Photo of flat tire on driver side, shortly after the incident. Photo of the bill from Midway
Ford Services (Had all four tires replaced but am asking for compensation for the cost of one tire and the vehicle alignment which totals $345.90).
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: Merrit Stoltzman <
Signature of Person submitting this form: Merrit Stoltzman
Relationship of person signing to Party making the claim: myself
Date document is being signed: 8/23/2023
Revised March 2023