Schmid, JessicaNOTICE 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 en@rety by clearly typing or prin@ng your answers to each ques@on. If you have addi@onal documenta@on you may add those
documents to your submission. You will not be contacted by telephone unless clarifica@on is needed. The claim process for inves@ga@ons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sec@ons completed. Submission is to the Saint Paul City Clerk’s Office. You may email, fax
(651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”
Individuals: First Name __Jessica_____________ Last Name __Schmid_____________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☐ They/ Them/Theirs ☐
Company or Business Name: __N/A___________________________________________________________________________
Is this claim being made by an Insurance Company? N/A If yes, what is your Claim/File Number?: __N/A______________
Is this claim being made by an AGorney? Choose an item. If yes, what is your File Number? ___N/A________________________
If yes, then provide your Insured’s/ Client’s Name __Jessica Schmid____________________________________________
Street Address: __781 Jessamine Ave E___________________________________________________
City: __Saint Paul________________________ State __MN_________________ Zip Code __55016________________
DayMme/Work Phone ___ N/A____________________________ Cell Phone __612-223-9536_______________________________
Date of Incident or Date Discovered (Must complete) __February 2, 2023______________Time __4:35PM________________
Please state, in detail, what happened that prompted you to file a NoMce of Claim Form. __The ice build up on Weide St. from lack
of plowing caused my vehicle to slide into a snow pile, damaging and breaking my front passenger side bumper, headlight, washer
fluid reservoir_______________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __Lack of City Plows to plow/salt snow and
ice to prevent ice build up - between 3 - 4 inches of ice present at @me of accident____________________________
Please check the reason that most closely describes the reason for your submieng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiGed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esMmates for repairs or actual bill that has been paid.
☐ Automobile damage from a street defect or pothole : please provide two es@mates 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 Mcket (if available), receipt
from Impound Lot, and two esMmates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing Mcket (if available), receipt from Impound Lot, and two esMmates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two esMmates 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 sec@on 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 __ N/A_______________
Revised December 2021
If yes, what law enforcement agency responded? __ N/A_____________________________________________________
Where did the incident take place? Please provide a street address, intersecMon or name of City park or facility.
___ north-facing side of Weide St., between Maryland Ave and Rose Ave, Saint Paul______________________
No@ce of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your saMsfacMon? __(1) full reimbursement of repairs to damage; (2) City
plows to Saint Paul ager snowfall accumula@on of 2” + (3) snowplows to sand and/or salt where ice build up impedes vehicles
ability to use streets safely _________________
Were there witnesses to this incident? Please provide names and contact phone numbers. __ N/A________________________
For property damage claims, including vehicle accidents.
Your vehicle’s informaMon: Year _2007___ Make _Toyota___________ Model _RAV4____________ Color __WHITE______________
License Plate # __ALF-173___________________ State vehicle is registered in __MN______________________
Registered owner of vehicle __Jessica Schmid_________________ Driver ___Jessica Schmid_______________________
Area(s) damaged __front passenger side bumper, suspension, washer fluid reservoir __________________________
If a City vehicle was involved: License Plate # ___ N/A____________________________ Color ____ N/A___________________
Was there City insignia on the vehicle? Yes No Driver’s Name __ N/A_______________________________________
Other property damaged: __ N/A______________________________________________________________________________
For injury claims of any type.
What part of your body was injured? __ N/A________________________________________________________________________
Did you go to the emergency room or urgent care? Yes No Where? ___ N/A______________________________________________
Was medical treatment received? Yes No Where? ___ N/A___________________________________________________________
First day of medical treatment? __ N/A___________ Are you sMll receiving medical treatment? Yes No
Did you miss any work as result of this incident? Yes No Employer(s) ___ N/A____________________________________________
How much Mme have you missed from work?__ N/A_________________________________________________________________
If you are submieng other documents, please state what you are akaching and how many pages. ______________________
By signing this form, you agree that all informa3on 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 prosecu3on under Minnesota Statutes.
Name of Person compleMng form: __ Jessica Schmid ______________________________________________
Signature of Person submiYng this form: ___ Jessica Schmid _____________________________________________________
RelaMonship of person signing to Party making the claim: __self_________________
Date document is being signed __ 02/08/2023 ___________
Revised December 2021