Aravena, Francisca
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
mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint 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: _Francisca___________________Last Name: __Aravena___________________________________
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? NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: ___5010 Yuma Ln N ____________________________________________________________________
City: ___Plymouth________________________________ State: ___MN________________Zip Code: ____55446_______________
Daytime/Work Phone: _______________________ Cell Phone: _____(612)999-3607__________________________________
Date of Incident or Date Discovered (Must Complete): 4/8/2023 Time: 8:30PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I am writing to submit a notice of claim regarding the damage to my vehicle resulting from a
pothole located on Ford Pkwy and Mt. Curve BLVD and in St. Paul. On April 8th, 2023, I was driving on this street when I hit a large pothole that was not properly marked. As a result
of this incident, the top left tire was damaged beyond repair and all four tires had to be replaced.
Please state why or how you feel the City of Saint Paul is responsible for your Damages: I believe that the city is responsible for the damage to my vehicle because the pothole was
not properly marked during the time of the incident. The lack of proper marking prevented me from avoiding the pothole, causing major damage to my vehicle. I have attached a copy of
the invoice for the tire replacement as evidence of the damages incurred.
As a resident of this city, I feel that it is the responsibility of the city to ensure that its streets are properly maintained and that hazards such as potholes are identified and repaired
in a timely manner. I respectfully request that the city reimburse me for the cost of the tire replacement, as I believe this damage could have been avoided if proper maintenance had
been conducted.Click or tap here to enter text.
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.
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:
____________________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? ____________________________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 ____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: __2019__ Make: _Honda______ Model: __Civic Sport Touring__ Color: __Light Blue___________
License Plate #: _CSN 632_________________ State vehicle is registered in: _____Minnesota______________________
Registered owner of vehicle: __Francisca Aravena_________________ Driver: ___Francisca Aravena_______________
Area(s) damaged:_Upper Left Passenger Tire________________________________________________________________
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? NO Driver’s Name</w: ______________________________________________________
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: I am submitting a copy of the invoice received by Discount Tires to replace all four 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: __Francisca Aravena___________________________________________________________ <
Signature of Person submitting this form: ___F.Aravena____________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 5/5/2023
Revised March 2023