Swinney, Steve
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: Steve____ Last Name: Swinney_______________________________________________
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: 5175Fairpoint N___________________________________________________________________________________________
City: _____Hugo_________________________________________ State: __MN______________________ Zip Code: 55038___________________
Daytime/Work Phone: _______________763-227-7935___________________ Cell Phone: 763-227-7935_____________________________________________
Date of Incident or Date Discovered (Must Complete): 5/23/2023 Time: ___5:15 A.M.__________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __I Ran over a pothole on my way to the airport on 7th St., My front drivers side tire went flat
immediately. I left it it the parking lot of Mickeys Diner and caught an Uber as to not miss my flight. I had it towed to Buerkle Body Shop in White Bear where they were able to fix
my rim which had damage and replace my tire.__________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _My car was damaged due to a pothole on a City street.___________________________________
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? YES / NO
If yes, please provide the police report case number: ___No________________________
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:
____________7th St. W, about a half block before Mickeys Diner________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? Reimburse me for damage to my car. The total for the damage is $856.27_________________________________________________________________________________________________
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 ______________________I
spoke with there employee at Mickey’s Diner to ask him not to have me towed.______________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: __2021_______ Make: ___Nissan______________ Model: __Maxima________________ Color: _____Slate Gray_____________
License Plate #: JHS 142 _________________________ State vehicle is registered in: ___MN________________________
Registered owner of vehicle: ___Steve Swinney__________________________ Driver: Steve Swinney__________________________________________
Area(s) damaged: Front drivers side rim and tire______________________________________________________________________________
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? YES / 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: _________________________
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: ___Steve Swinney__________________________________________________________ <
Signature of Person submitting this form: ____Steve Swinney___________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 5/11/2023
Revised March 2023