Pawlenty, JacobNOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota
Minnesota State Statute 466.05states that '..everyperson...wha claims damagesfrom any municipality...shallcause to be presented to the governing body ofthe
municipality within 180days after the alleged loss orinjuryis discovered a noticestatingthe time,place,and circumstances thereof,andthe amount ofcompensation
or other reliefdemanded."
Pleasecomplete this form in its entirety by clearlytypingor printingyouranswers 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 jI fax
(651-266-8574)or mail the form.Mailingaddress is "Saint Paul City Clerk,15 West Kellogg Blvd.,Suite 310,Saint Paul,MN 55102"
Individuals:First Name Jacob Last Name Pawlenty
Please Indicate Your Pronouns:She!Her/Hers L1 He/Him/His _They/Them/Theirs E
Company or Business Name:
Is this claim being made by an Insurance Company?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?_________
Ifyes,then provide your Insured's!Client's Name
Street Address:24185 St.Croix Trail North
City:Scandia State MN Zip Code 55073
Daytime/Work Phone Cell Phone 651-219-8535
Date of Incident or Date Discovered (Must complete)3/20/2023Time 0620
Please state,in detail,what happened that prompted you to file a Notice of Claim Form.
On 03/20/2023 at approximately 0620 hours,I (Jacob Pawlenty)was driving East on 7Th Street in St.Paul approaching the Highway
35E on ramp when I drove through a significant and sizeable pothole causing both my front and rear passenger wheels to be dented
in a such a way both tires went flat,pictures of the damages will be attached as a supplement to this claim form.I have worked as a
Police Officer for the past 17 years and was advised by a colleague that this claim form seeking relieffrom financial damages could
be filed.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
The City of St.Paul has a duty to its citizens to maintain the roads we are so heavily taxed to operate motor vehicles on.It is my
belief this area has been problematic for an extended period.The repair shop approximately 1 city block from where the damage to
my vehicle occurred stated no less than 12 other vehicles suffered the same fate as my own.I called the St.Paul Department of
Public Works (651)266-6100)to report the issue and I was told they would document my complaint but would not provide any
information on how many complaints had been filed before mine (There were several,one from my repair shop)and refused to
state how long the City of St.Paul had been aware of the hazard.I can only assume this is to deny culpability.I am a single father of
two,and if I hadn't been paid only days prior to the incident I would have not been able to fix my vehicle.If there is a person tasked
with reading this,which I sometimes doubt our local governments commitment to its citizens,I'm only asking to be made whole,I'm
not looking for a handout.I am a hard-working tax paying citizen.
Please checkthe 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.
E 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.
fl 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.
E 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.
LI You were injured during a motor vehicle accident:please provide police report number,details about injury.
LI 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?
Revised December2021
Where did the incident take place?Please provide a street address,intersection or name of City Park or facility.
7th Street West and Lexington Pkwy S
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 to be reimbursed for the damages to my
vehicle,totaling $936.74.I am not asking for damages for missing work (I'm a federal employee and have sick time available to me).
Were there witnesses to this incident?Please provide names and contact phone numbers.It was early morning,traffic was light,I
do not have any witness information to provide currently.
For property damage claims,including vehicle accidents.
Your vehicle's information:Year 2008 Make Chevy Model Malibu Color Silver
License Plate #FFL661 State vehicle is registered in Minnesota
Registered owner of vehicle Jacob Pawlenty Driver Jacob Pawlenty
Area(s)damaged Front passenger side wheel.Rear passengersidewheel
If a City vehicle was involved:License Plate #
Was there City insignia on the vehicle?Yes No Driver's Name
Other property damaged:
For injury claims of any type.
What part ofyour body was injured?_______
Did you go to the emergency room or urgent care?Yes No Where?
Color
Was medical treatment received?Yes 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)Department of Veterans Affairs
6:07 dIII 89%i
.1
¯1
passenger front and passen
will not hold air will need ne
res to be put on
II 0
present when I hit the potho
Customer ID:2378046718
Name:JAKE PAWLENTY
ddress:24185 SR CROIX TR N
ddress 2:
CityState,Zip/Postal Code:SCANDIA,MN,55073
Home Phone:(651)219-8535
fVork Phone:OijlobilePhone:0 -
Tax Exempt#:
Service comments:
Salesperson:K.KRAUS
MIDASAUTO SERVICE CENTER
1697 WESTSEVENTH STREET
SAINT PAUL,MN
(651)728-6982
Year:08
Make:CHEVROLET
Model:MALIBU
LicNo:FLL66I
VIN:1G1ZH57B28F181270
Color:
Engine:2.4L 14 F DO
Mileage In:168791
Mileage Out:168791
PAGE 1
Date/Time:03/20/23 16:56:07
Estimate #:186237
Invoice 1/:259723
KeyTag:
P0 Number:
Email Address:na
Fleet/Wholesale:N
Unit Number:
Oty.Part#RFR Loc Description List Labor Total Thank you for your patronage.
At MidasAuto Service Centers
ALIGNMENT our goal is 100%customer
I ALT RA THRUSTALIGNMENT 0.00 99.99 99.99 satisfaction.If you have any
TOTAL ALIGNMENT:99.99 comments or concerns,please call
Franchise ownerAdam Stranik
TIRES 651-789-5668
2 1951307502 RA 225/5OZR17XLZENNABLK 112.99 0.00 225.98 ThankYou.
Tire Size:2255017
Load Rating:98
DOT Numbers:IKAVMYRLZ4122 IKAVMYRLZ4222
TOTAL TIRES:225.98
WHEEL SERVICE
2 *057937 RB WHEEL (USED)193.99 25.00 437.98
2 TPMSKIT RA A TPMS SERVICE KIT 9.99 0.00 19.98
2 RHW RA TIRE PROTECTION PLAN 19.50 0.00 39.00
2 BAL RA BALANCE WHEEL 2.00 0.00 4.00
2 TM RA TIRE MOUNTING 0.00 18.00 36.00
2 TD RA TIRE DISPOSAL 5.25 0.00 10.50
TOTAL WHEEL SERVICE:547.46
**CustomerWishes To Discard Old Parts
These Parts And/OrServices Were Deólined by the Customer:
I ALT3 RA 3YRALIGNMENT 0.00 149.99 149.99
2 15153NXK RA 225/50R17TN PRIZAHS B 139.99 0.00 279.98
2 166032002 RA CS5UltraTouring 179.99 0.00 359.98
Total Declined Service Recommendations:789.95
RA PART NO LONGER PERFORMS INTENDED PURPOSE
RB PART DOES NOT MEETADESIGN SPECIFICATION
PAY AMOUNT SHOPSUPPLIES 8.50
CASH 950.00 PARTS TOTAL 687.44
CHANGE (13.26)SALES TAX 54.81
LABOR TOTAL 185.99
TECH:007005-0.00 C.PAZDERNI}<GRAND TOTAL 936.74
007044-0.00 0.DESPENZA
WWW.GOMIDAS.COM
INVOICE INVOICE MIDAS AUTO SERVICE CENTER INVOICE
Ifyou are submitting other documents,please state what you are attaching and how many pages.I have attached an invoice for
my bill from Midas,which I paid in full.I will also attach photographs ofthe damage to my passenger side front and rear wheels and
tires,and the pothole.The pictures of the pothole were taken several days after I damaged my vehicle,and the traffic cone was not
By signing thisform,you agree that all information provided is true and correct to the best ofyour knowledge.
Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes.
Name of Person completing form:
Signature of Person submitting thi
Relationship of person signing to
Date document is being signed 2_i I
RevisedDecember2021