Stark, Kyria
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: _Kyria_________________________ Last Name: _Stark_________________________________________
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ___NA_______________________________________________________________________________
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: _______________________________________________________________________
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Street Address: ______5536 28th Ave S________________________________________________________________________
City: Minneapolis ____________________________________ State: __MN________________ Zip Code: _55379____________
Daytime/Work Phone: _952.451.7136___________________ Cell Phone: ___952.451.7136_______________________________
Date of Incident or Date Discovered (Must Complete): 4/26/2023 Time: ___8:30 a.m.________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: While driving my car North/East bound on Hwy 5 in St. Paul, I hit a very deep pothole that bent
my rim and caused my tire to no longer hold air. The rim and tire damage </wwas so bad that both the rim and tire had to be replaced. ____________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? This pothole was so deep that my entire car bottomed out and caused a steel rim to be bent on
both the inside and outside of the mounting </wsurface.___________________
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. I only have one <estimate and this is where the work was
done to repair the car. This is the shop we use for all of our car repairs including the rest of the tires on the car were purchased so we had to use that place to ensure match and
future warranty of the tires.
☐ 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:
_Highway 5 / 7th Street – heading northeast bound, just after the Planet Fitness, but before Interstate 35 North. ____________
What would you like to see happen to resolve this claim to your satisfaction? _Would like to be reimbursed for the cost of the tire and wheel. _________________________________________
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 _No witnesses identified
at time of pothole
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2010______ Make: _Chevy__________ Model: _Malibu___________ Color: _White___________
License Plate #: CLD 648___________________ State vehicle is registered in: __Minnesota_________________
Registered owner of vehicle: _Greg Stark_________________ Driver: _Kyria Stark ____________________________
Area(s) damaged:___Front Drivers side Wheel and 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? No___________________________________________________________________________
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? 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: Attaching 2 additional docs:tire_picture – picture of tire and rim damagetire_invoice –
picture/scan of invoice paid for repair_________________________
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: __ Greg Stark____________________________________________________ <
Signature of Person submitting this form: ___Greg Stark_______________________________________________
Relationship of person signing to Party making the claim: _Father_____________________________________
Date document is being signed: 5/17/2023
Revised March 2023