Walker, SamanthaNOTICE 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 Samantha Last Name Walker
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? Choose an item. If yes, what is your File Number? NO_________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: __1002 Jessie Street, Unit 1, _______________________________________
City: _ Saint Paul ___________________________________________ State ___ MN __ Zip Code ___55130_______________
Daytime/Work Phone _______________________________ Cell Phone ___612-205-9265______________________________
Date of Incident or Date Discovered (Must complete) 3/17/2023Time ___11:30 AM______________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. __Rim bent due to potholes/ street
condition, tire almost off. Cost is so much $297 to replace rim, change sensor to new rim/ wheel, and put tire back on
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __The road conditions are severe and not
being addressed in a timely manner. Some potholes on Shephard Road, Payne, Maryland, and other main roadways are large enough there is no way to go around. I am a careful driver, slow down with weather and potholes, and attempt to avoid them- some
were unavoidable and unexpectedly deep when impossible to avoid (Shephard road as I lived on Davern until 3/8).
____________________________
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.
________________________________________________________________________________________________________
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 to me or pay Inver Grove Honda
directly for total $297 or even half would help!______________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year __2012____ Make Model Avenger__________ Color _Gray______
License Plate # _____MNB 647________________ State vehicle is registered in ___MN_____________________
Registered owner of vehicle _Samantha Walker__________ Driver Samantha Walker__________________________
Area(s) damaged _____Front passenger side wheel/ rim dented to the point the tire was coming off and losing air__
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: Samantha Walker__________
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