Selseth, Rawley
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: Rawley Last Name: Selseth Click or tap here to enter text.
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: 9292 Dartford Rd.
City: Woodbury </w State: MN < Zip Code: 55125<
Daytime/Work Phone: __________________________________ Cell Phone: 651-322-0707
Date of Incident or Date Discovered (Must Complete): 5/23/2024 Time: 7: 35 am </
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: <Hit huge pothole on Lower Afton Rd which resulted in a flat tire immediately and a scraped
rear rim.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? This pothole is clearly big enough to be damaging vehicles and should be fixed. I’ve seen road
workers around the immediate area of this pothole but it wasn’t fixed.
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:
Lower Afton Road & Point Douglas Road – right before Highway 61.
What would you like to see happen to resolve this claim to your satisfaction? I would like the pothole to be fixed and to be reimbursed for the damages to my car. I also missed a day
of work because I couldn’t drive my car the distance to my job. I had to turn around and drive instead to a repair shop as I knew my tire was severely damaged and going flat. The repair
shop finished the repair around 3:00 that afternoon, causing me to miss a full day of work.
Were there witnesses to this incident? <No. < Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 Click or tap
here to enter text.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: <2024 Make: Subaru < Model: Impreza RS </ Color: Black Click or tap here to enter text.
License Plate #: _______LPN486__________________ State vehicle is registered in: ______MN_____________________
Registered owner of vehicle: __________Rawley Selseth___________________ Driver: _Rawley Selseth
Area(s) damaged: F</ront tire damaged beyond repair & rear rim significantly scraped
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? __No ____________________________
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 <
Employer(s): _______________________Bubbly Paws, St. Paul
How much time have you missed from work? ______1 day________________________
If you are submitting other documents, please state what you are attaching and how many pages: Submitting four items: paid invoice from the tire repair shop, plus three pictures of
the pothole and area. I will be getting an estimate for the repair to the back rim of the passenger-side
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: ______Rawley Selseth_______________________________________________________ <
Signature of Person submitting this form: Rawley Selseth <
Relationship of person signing to Party making the claim: ___________Self_______________________________
Date document is being signed: 5/25/2024
Revised March 2023