Sweeney, KristaNOTICE 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 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 Krista____________________________ Last Name _Sweeney_____________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☒ He/Him/His ☐_ They/ Them/Theirs ☐
Company or Business Name: NA______________________________________________________________________________
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, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: 1663 Niles Avenue_______________________________________________________________________________
City: Saint Paul_____________________________________ State MN___________________ Zip Code 55116__________________
Daytime/Work Phone _612-360-5337______________________________ Cell Phone _612-360-5337________________________
Date of Incident or Date Discovered (Must complete) 1/20/2023Time _11:00 AM CST________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was driving North on Cleveland, coming
up to the Summit Ave. corner intersection. The Summit Ave./Cleveland corner intersection had a significant amount of ice and snow
on the right side, extending into and beyond the bike lane area, due to lack of plowing by the city. There were several cars heading
South on Cleveland as I approached the intersection. The safest option for not only myself but also the other vehicles in passing was
to stay in my lane. My right, front tire wheel hit the pothole causing significant cut/tear on the interior wall of the tire, exposing,
and damaging the structure of the tire causing an immediate deflation of the tire. The tire was only a year old, on a new car and had
40-50,000 more safe drivable miles.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The City of Saint Paul is responsible to
provide safe and well-maintained streets for myself and other citizens travelling along this avenue. The location of this pothole is
dangerous, as it is located on the right side of the right-hand lane, with no clear shoulder access for possible safe passage. ANYONE
who attempts to avoid this pothole will either need to swerve into the left-hand lane, potentially into oncoming traffic causing an
accident OR onto icy snow patches, potentially causing the vehicle to slide into the snowbank and cause more damage. The location
of this pothole is on Cleveland Ave, a high traffic area, and it is negligence on the part of the City of Saint Paul to NOT have had this
pothole patched and fixed immediately (see pictures – date of pictures is 01/21/2023, one day after the damage to my vehicle.) If
the damage was only a breaking of the seal, the tire could have been saved, unfortunately the damage resulted in an unrepairable
tire, and therefore to maintain the safety for my family and the proper performance and long-term operation of our vehicle we were
required to replace all 4 tires.______________________________
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.
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 ____________________
Revised December 2021
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.
Right before the corner of Cleveland and Summit Ave (right hand lane heading North)_______________________________
Notice 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 satisfaction? $1,087.51 reimbursement for the damage to my
vehicle AND the pothole on Cleveland to be patched._________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. No______________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2022______ Make _Volvo_____________ Model ___XC60_______ Color _Black_______________
License Plate # _GWL968____________________ State vehicle is registered in __MN______________________
Registered owner of vehicle Michael Sweeney_(Husband)_________________ Driver ______Krista Sweeney____________
Area(s) damaged _All four tires (front, right primary)________________________________________________
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? _____________ 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. Attaching photos of the
pothole, location, and the paid receipt from Discount Tires – University Ave – St. Paul for the repairs. I did receive an alternative
quote from Kline Volvo – Maplewood, for $1,360, but chose the lower cost alternative. _______
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: _Krista Sweeney_______________________________________________
Signature of Person submitting this form: ____________________________________________________________________
Relationship of person signing to Party making the claim: Self___________________
Date document is being signed 1/22/2023
Revised December 2021