Barry, Kate
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 is to the Saint Paul
https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may <
mailto:cityclerk@ci.stpaul.mn.usemail, 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 __Katherine_______________ Last Name __Barry_______________________________
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, then provide your Insured’s/ Client’s Name ____________________________________________________________
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Street Address: ___55 Livingston Avenue, #227_____________________________________________________________________
City: __Saint Paul_____________________________________ State __MN_____________ Zip Code _55107________
Daytime/Work Phone _734-730-5829___________ Cell Phone _734-730-5829__________________________________
Date of Incident or Date Discovered (Must complete) 3/4/2023Time __2:30pm________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _I was driving northbound on Robert Street at the intersection with Congress Street E and was
unable to avoid an extremely deep pothole in the road. I had to swerve to avoid two other potholes just prior to the big one, but I was unable to swerve to avoid the large, deep pothole
because I would have been in danger of colliding with oncoming traffic. It was impossible to see how deep this potholes was, and even at a slow driving pace it caused my tire to break
and need to be replaced._________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _I recognize this winter has been difficult for the roads but this pothole is egregiously deep
and dangerous and the city should prioritize repairing such dangerous potholes._
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.
_Northbound lane of Robert Street at Congress St E. __________________________________________________________
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? _I would like the pothole to be fixed and to be reimbursed for the cost of my replacement tire, which is
$133.70. _____________
Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year __2014____ Make __Ford_______________ Model ___Fiesta_________________ Color ____Gray____________
License Plate # __NBJ153___________________ State vehicle is registered in ___Minnesota_____________________
Registered owner of vehicle __Katherine Barry___________________ Driver _____Katherine Barry______________
Area(s) damaged ____Tire________________________________________________________________________
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. _Invoice for replacement tire and installation____
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: __Katherine Barry_________________________ <
Signature of Person submitting this form: ______________________________________________________________________
Relationship of person signing to Party making the claim: __Self__________
Date document is being signed 3/6/2023
Revised December 2021