Osman, AustinRevised March 2023
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 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 Name: ______________Austin__________ Last Name: _______Osman____________________________________
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? YES / NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ____________5721 Standish Ave_________________________________________________
City: _____Minneapolis________________ State: ______MN__________ Zip Code: _______55417________
Daytime/Work Phone: ___320-828-3738__________________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): _________January 19th, 2023____ Time: ______15:05_____________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: Unavoidable large pothole on West 7th,
shredded right front tire wall
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Regular street maint. Is responsibility of
city. Potholes deep enough to see streetcar-rails should be filled promptly!
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.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
Revised March 2023
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? ____________________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
________West 7th/Fort Road near Victoria Street
What would you like to see happen to resolve this claim to your satisfaction?
________________Reimbursement for tire replacement, AWD vehicle required 4 new tires
Were there witnesses to this incident? Please provide names and contact phone numbers:
______________________None___________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2014___ Make: ___Subaru______ Model: ____Impreza______ Color: ____Black________
License Plate #: _____214PGM_____________ State vehicle is registered in: ___MN___________
Registered owner of vehicle: __________Austin Osman_______ Driver: _________Same________________________
Area(s) damaged:___________Right Front Tire Destroyed_________________________________________________
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: _______Austin Osman__________________________________________
Signature of Person submitting this form: ____________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: ____4/12/2023___________