Woitas, Judith
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 Judith Last Name </Woitas Address </w1888 Princeton Ave, St Paul, MN 55105
Please Indicate Your Pronouns: She/ Her/Hers _X__ He/Him/His ____ They/ Them/Theirs _______
Company or Business Name: N/A_________________________________________________________________________
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: _________________________________________________________________________________________
City: ____________________________________________ State _______________________ Zip Code __________________
Daytime/Work Phone _______________________________ Cell Phone ____________________________________________
Date of Incident or Date Discovered (Must complete) ___3/12/23________________Time 4:30PM_________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form.
Driving South bound on Fairview Ave a pothole was seen to the left side of street; moving to the right to avoid it, hit another pothole (right front). Could be seen that the tire was
beginning to deflate and that the wheel was bent and the wheel cover broken.
Please state why or how you feel the City of Saint Paul is responsible for your Damages
No warning indicators were in place and the damage causing potholes were not attended to.
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.
_X_ 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? Yes <No
If yes, please provide the police report case number ____________________
If yes, what law enforcement agency responded? No
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
Southbound lane of Fairview Ave beneath the I94 overpass
What would you like to see happen to resolve this claim to your satisfaction? Would like the damaged wheel tire and wheel cover replaced.
Were there witnesses to this incident? Please provide names and contact phone numbers. Driver, David Little 651-698-1904 and passenger, Judy Woitas_651-279-8826
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2009 Make Hyundai Model Accent Color Dark grey
License Plate # PAB 653 State vehicle is registered in Minnesota
Registered owner of vehicle Judith Woitas Driver David Little
Area(s) damaged Passenger side front
If a City vehicle was involved: License Plate # NA Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________
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? _________________________________________________
Was medical treatment received? Yes No Where? ______________________________________________________________
First day of medical treatment? N/A 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.
Five photos and repair estimate
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: Judith (Judy) Woitas
Relationship of person signing to Party making the claim: self
Date document is being signed March 20, 2023
Signature of Person submitting this form:
_______________________________________________________________________
Revised December 2021