Memphis, NickNOTICE 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 this completed form to the Saint Paul City Clerk’s Office by email
(cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint
Paul, MN 55102”.
Claimant: First and last Name: Nick Memphis
Please Indicate Your Pronouns: She/Her/Hers, He/Him/His, They/ Them/Theirs
Company or Business Name: N/A
My Info:
Street Address: 1413 Farrington St. Unit A
City: St. Paul Zip: 55117
Daytime/Work Phone: Cell Phone: 612-799-1341
Date of Incident or Date Discovered (Must Complete): 4/10/23 Time: 6pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:
My front driver's side tire has some serious bulging (from potholes in St. Paul). The tire buldging is bad
enough to replace immediately as it was not safe top drive (confirmed by the Discount Tire employee).
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
Heavy question. We all know the St. Paul roads are suffering this year. Some of the roads are almost
impossible to drive on. This particular road(s) are covered in potholes. Several weeks ago there was an
attempt to cover SOME of them, but it was a cold and rainy day so none of the fillings lasted more than a
few days.
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 street defect or pothole: please provide two estimates for repairs or actual
bill that has been paid.
Attachment of bill to replace (1) tire and install.
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Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in
delays.
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:
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:
Arlinton Ave W between Farrington and Rice AND/OR Jackson St. between Arlington and Maryland. These
were to two roads I was traveling on to and from when I do believe the incident happened.
What would you like to see happen to resolve this claim to your satisfaction? Cost of (1) replacement tires
and installation. $175 for the exact tire as the other 3. $22 for install. $197 total.
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Were there witnesses to this incident? N/A Please provide names and contact phone numbers:
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2011 Make: Mazda Model: 6 Color: Sangria Red
License Plate #: AVH-605 State vehicle is registered in: MN
Registered owner of vehicle: Nick Memphis
Area(s) damaged: Front Driver's Side Tire
If a City vehicle was involved, License Plate #: _ Color:
Was there City insignia on the vehicle? Driver’s Name:
Other property damaged:
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: Nick Memphis
Signature of Person submitting this form: Nick Memphis
Relationship of person signing to Party making the claim:
Date document is being signed: 4/11/23
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