Buck, Kirstin
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 _Kirstin___________________________ Last Name Buck
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: 624 Thoreau Drive
City: Burnsville State MN Zip Code 55337
Daytime/Work Phone Click or tap here to enter text. Cell Phone 507-301-4231_
Date of Incident or Date Discovered (Must complete) 3/11/2023 Time 5:20 PM_________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _While driving at the posted speed limit, within the solid white line (not the bike lane),
a pothole in the lane caused a flat tire and damaged the tire rim on the front, passenger side of my vehicle (2013 Volkswagen Passat). ____________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The City of Saint Paul is responsible for maintaining city streets, and Fairview Avenue North
specifically. Unrepaired damage on Fairview Avenue North caused damage to my vehicle.
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.
Southbound lane, of Fairview Avenue North, across from address 220 Fairview Ave N, St Paul, Minnesota.
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 costs ($977.57) to repair damage caused by a pothole on Fairview Avenue North. Costs:Labor
(for tire and wheel/rim work): $106.044 Tires ($646.0), divided by 4 for the cost of 1 tire: $161.50Tire disposal fee: $13.96Alignment: $129.99 *Required when replacing tires and wheel/rim.Wheel/rim:
$566.08$106.04 + $161.50 + $13.96 + $129.99 + $566.08 = $977.57
Were there witnesses to this incident? Please provide names and contact phone numbers. The incident was witnessed, but the witnesses are not known.______________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2013 Make: Volkswagen Model: Passat____________________ Color: Black
License Plate # 5CN411_____________________ State vehicle is registered in Minnesota
Registered owner of vehicle Kirstin Buck Driver Kirstin Buck
Area(s) damaged Front passenger tire, front passenger tire rim
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. Included at the end of this document: -Images of pothole damage taken by Honest-1 Auto
Care Burnsville on 03/13/2023-Communication from AAA to change the tire 03/11/2023
-Images of potholes taken on 04/07/2023
Attached:
- Invoice from Honest-1 Auto Care Burnsville for pothole automotive vehicle damage repair (4 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: Kirstin Buck________________________________________________ <
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: Self___________________
Date document is being signed 3/31/2023
Revised December 2021
Images of pothole damage taken by Honest-1 Auto Care Burnsville, images taken on 03/13/2023
Communication from AAA to change the tire on 03/11/2022
Images of potholes taken on 04/07/2023