Dalton, Lawrence
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 Lawrence Last Name: Dalton
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? </w:t </wNo </w:t>< If yes, what is your Claim/File <Number?: _____________________
Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
</
Street Address: 1910 Bohland Avenue
City: St. Paul < State MN </w Zip Code 55116<
Daytime/Work Phone 608.780.6148 Cell Phone 608.780.6148_
Date of Incident or Date Discovered (Must complete) 2/15/2023Time <approximately 9:00 pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. My daughter, Chelsea Dalton, hit a pothole and destroyed her right front tire. I paid for
the repair bill in partial payment for her dog-sitting our pet. Her statement is attached. The invoice from Firestone (also attached) is for two tires, a serpentine belt, and a brake
light. The repairman had advised us to replace two tires rather than just the one, so we did. I am filing this reimbursement request for only the one tire that was destroyed by the
pothole, not the second tire, belt or brake light. The amount of the tire replacement includes balancing, valve and scrap tire fee for a total of $184.50. <
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The damage was caused by a pothole on a city-maintained street.
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 Cleveland Avenue between Eleanor & Pinehurst
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 City of St. Paul to reimburse me $184.50.
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 2008 Make Honda </ Model Accord </ Color Blue</
License Plate # JVN747 State vehicle is registered in Minnesota</
Registered owner of vehicle: Chelsea Dalton </Driver: Chelsea Dalton</
Area(s) damaged Right front 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. Email from Chelsea Dalton (1 page), Invoice from Firestone (2 pages)
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: Lawrence Dalton. < <
Signature of Person submitting this form: Lawrence Dalton <
Relationship of person signing to Party making the claim: self
Date document is being signed 3/8/2023
Revised December 2021