Tessman, RyanRevised 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: _Ryan ______________________ Last Name: _____Tessman_________________________________
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? _______No_______________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _________________No__________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: __________343 Oneida Street_____________________________________________________________________
City: ____Saint Paul_________________________________ State: _Minnesota________________ Zip Code: ____55105________
Daytime/Work Phone: _____612-743-8884__________________ Cell Phone: ____________612-743-8884___________________
Date of Incident or Date Discovered (Must Complete): 4/20/2023 Time: ______Approx. 11:00 pm_____________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___I was driving home from the Planet
Fitness gym on West 7th to my house on Oneida and experienced significant potholes. I tried to avoid the worst of the potholes but
it was dark out and I did end up hitting a wide pothole right in the middle of West 7th near Montreal. I immediately noticed that my
car was pulling to the left as I drove and pulled over to examine the damage. My wheel was bent on the drivers side but I was able
to get home on the tires. The next morning the front drivers tire was completely flat and the front passengers tire was in poor
shape. I put on a spare on the drivers side and was able to fill up enough air in the passengers side that I could make it to discount
tires where they informed me I would need a new wheel and two new tires. One of the wheels was damaged but they were able to
bend it back into shape. _________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___ I believe the City of Saint Paul is
responsible for my damages because the pothole that caused my tires to pop was located on a road maintained by the City. As a
driver, I rely on the City to properly maintain the roads to ensure safe driving conditions. The pothole was large and deep enough to
cause significant damage to my tires and wheel, which would not have happened if the City had fulfilled its duty to maintain the
road. Therefore, I am seeking reimbursement for the replacement tires and wheel that were damaged as a result of the City's
negligence in maintaining the road. _________________________________
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.
Revised March 2023
☐ 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.
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:
________This occurred on West 7th just before the intersection with Montreal Ave_______________________________________
What would you like to see happen to resolve this claim to your satisfaction?
_____________I would like reimbursement for the replacement tires and wheel__________________________________________
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: 2016_____ Make: __Honda__________ Model: _____Fit__________ Color: ____Black_________
License Plate #: _______JCF 506__________ State vehicle is registered in: ___Minnesota_________________
Registered owner of vehicle: ___Ryan Tessman_______________ Driver: __Ryan Tessman______________________
Area(s) damaged:_____Front driver’s tire, front driver’s wheel, front passenger’s tire______________________________
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? _____________________________________________________________________
Revised March 2023
If you are submitting other documents, please state what you are attaching and how many pages: __2 pages total: picture of tire,
repair invoice from Discount Tires____
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: ___Ryan Tessman___________________________________
Signature of Person submitting this form: ____Ryan Tessman_____________________________________
Relationship of person signing to Party making the claim: ____Self__________________________
Date document is being signed: 4/25/2023