Potter, AnnaNOTICE 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 __Anna_____________________ Last Name ______Potter__________________________________
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 ____________________________________________________________
Street Address: _______________2121 Iglehart Avenue______________________________
City: __Saint Paul________________________________ State _____MN______________ Zip Code ________55104__________
Daytime/Work Phone ______651-266-6058__(prefer cell)______ Cell Phone _____402-203-9653_______________________
Date of Incident or Date Discovered (Must complete) 3/9/2023 Time ____1845_____________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. __After turning from WB Ford Parkway to
NB Cretin, I ran over several large potholes on Cretin Avenue. It was dark and I could not see them until it was too late for me to
avoid. There were also so many large potholes that I don’t know if I could have avoided them without going into oncoming travel
lanes, even if I was able to see them. The next day I noticed that my front tire was not holding air. We took the car in to get the tire
repaired and the mechanic indicated that the type of damage to the tire is typical after running over potholes. We had to replace an
essentially new tire.____
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __The potholes on Cretin were unavoidable
and damaged an essentially new tire beyond repair. _____
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.
___On Cretin Avenue, north of Ford Parkway. Approximately 790 Cretin Avenue. ____________________________
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? _Reimbursement for tire replacement costs ($340.68)_
Were there witnesses to this incident? Please provide names and contact phone numbers. _____no witnesses ____________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2021__ Make Hyundai Model ____Santa Fe________________ Color ____Stormy Sea_______
License Plate # ____GZX 206__________ State vehicle is registered in _____MN_______________
Registered owner of vehicle _________Anna Potter_________ Driver ____Anna Potter_______________________
Area(s) damaged ________________front tire_________________________________________________________
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? __________________________________________________________________________
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. ______________________
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: __Anna Potter______________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: _____same person______________
Date document is being signed 4/4/2023
Revised December 2021