Deutz, AnthonyNOTICE 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 Anthony___________________ Last Name Deutz______________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☒_ They/ Them/Theirs ☐
Company or Business Name: __N/A______________________________________
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? __N/A________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: __2128 Cottage Ave E. __________________________________________
City: St. Paul__________________________ State MN Zip Code 55119 __________________
Daytime/Work Phone _612-366-7877______________________ Cell Phone Same _
Date of Incident or Date Discovered (Must complete) 2/1/2021, 3/22/2021, 2/14/2023Time __2am, 9pm, 8:40pm,
respectively_______________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I found out I could possible recover some
of my losses this way____________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Because the roads are not being properly
maintained in my neighborhood. I pay taxes and we deserve better. _____________________________
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? Yes No If yes, please provide the police report case number _NO___________________
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.
E. Maryland Ave, Ivy Ave E., McKnight Rd (Please see attached map for specific locations. _________________
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? __As much money reimbursed as possible. ____
Were there witnesses to this incident? Please provide names and contact phone numbers. _Unsure if anyone saw_____
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2019__ Make Cadillac Model _XTS Luxury___________________ Color Black________________
License Plate # __CAJ 867_______________ State vehicle is registered in ____MN____________________
Registered owner of vehicle _Anthony Deutz_____________ Driver ___Anthony Deutz_______________________
Area(s) damaged Multiple wheels, tires, undercarriage_________________________________________
If a City vehicle was involved: License Plate # _____________N/A__________________ 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? ______N/A____________________________________________________________________
Did you go to the emergency room or urgent care? NO Where? _________________________________________________
Was medical treatment received? 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) 1 day in court (Self-employed) relating to most recent (3rd)
incident. No time missed due to 2nd incident. Don’t recall for 1st incident.
How much time have you missed from work?__at least a day because I did not have transportation.
If you are submitting other documents, please state what you are attaching and how many pages. Correspondence, multiple
repair receipts, spreadsheet of incidents, map
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: ___Anthony P. Deutz____________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 5/6/2023
Revised December 2021