Breiholz, RachelNOTICE 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: Rachel Last Name: Breiholz
Please Indicate Your Pronouns: She/ Her/Hers ☒ He/Him/His ☐_ They/ Them/Theirs ☐
Company or Business Name: N/A – Personal Vehicle
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number?: N/A
Is this claim being made by an Attorney? NO If yes, what is your File Number? N/A
If yes, then provide your Insured’s/ Client’s Name: N/A
Street Address: 1877 Randolph Ave., Apt. 3
City: St. Paul State: MN Zip Code: 55105
Daytime/Work Phone: 651-366-1007 Cell Phone: 651-366-1007
Date of Incident or Date Discovered (Must complete) 4/2/2023 Time: Approximately 4:15 PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was driving my 2023 Honda Civic with
slightly over 1,000 miles down Randolph Ave. I hit a pothole within a couple blocks west of the Snelling Ave. S./Randolph Ave.
intersection. Within a couple seconds of feeling my car hit the pothole, both the passenger in my car and myself heard and saw the
tire pressure light come on. I drove to the Snelling Ave. S/Randolph Ave. intersection and took a left, driving to the parking lot
behind 272 Snelling Ave. S., St. Paul, MN 55105. I got out of the car to check the tire pressure at which point, my passenger and
myself noticed the front right tire was completely flat. I parked my car and got a ride home with my friend. Once home, I contacted
roadside assistance to assist with putting on a spare tire. The front right tire of my vehicle will need to be replaced.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I believe the City of St. Paul is responsible
for the damages as the potholes on Randolph Ave. have become very large and are nearly impossible to avoid with the cars parked
on both sides of the street. Despite numerous attempts to fill the potholes, my car regularly bottoms out when driving. The car I
own is virtually brand new with slightly over 1,000 miles on it. The tires are nowhere near needing to be replaced. At the time of
the incident, I was traveling at an appropriate speed.
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
(see attached).
☐ 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: N/A
Revised December 2021
If yes, what law enforcement agency responded? N/A
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
I hit a pothole within a couple blocks west of the Snelling Ave. S./Randolph Ave. intersection.
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? Payment of the bill by the City of St. Paul to replace the
damage on the car.
Were there witnesses to this incident? Please provide names and contact phone numbers. Megan Dalldorf/ 4319-(651) 468
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2023 Make: Honda Model: Civic Color: Black
License Plate # KHP 711 State vehicle is registered in: MN
Registered owner of vehicle: Rachel Breiholz Driver: Rachel Breiholz
Area(s) damaged: Front right tire
If a City vehicle was involved: License Plate # N/A Color: N/A
Was there City insignia on the vehicle? NO Driver’s Name: N/A
Other property damaged: N/A
For injury claims of any type.
What part of your body was injured? N/A
Did you go to the emergency room or urgent care? NO Where? N/A
Was medical treatment received? NO Where? N/A
First day of medical treatment? N/A Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? NO Employer(s) N/A
How much time have you missed from work? N/A
If you are submitting other documents, please state what you are attaching and how many pages. Attached bill paid for damages.
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: Rachel Breiholz
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed _____________
Revised December 2021
4/18/2023