Conley, Timothy
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: Timothy Last Name: Conley
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? <Click or tap here to enter text.
Is this claim being made by an Attorney? NO. If yes, what is your File Number? Click or tap here to enter text.
If yes, provide your Insured’s/ Client’s Name: N/A
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Street Address: 752 Desoto Street
City: St. Paul State: MN. < Zip Code: 55130
Daytime/Work Phone: 651-313-4178 </ Cell Phone: 651-313-4178
Date of Incident or Date Discovered (Must Complete): 4/8/2023 < Time: 10:45 A.M.
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I was driving just under the posted speed limit due to the numerous potholes. However, it is
like driving an obstacle course and difficult to avoid all of them. Tried to quickly swerve around it but the damaged area extends across the entire lane. I also recently purchased these
tires on, 2-10-2023. The unexpected expense of tire repair, towing charge and any missed work time is a hardship I cannot afford. I feel I should not have to pay for a damaged street
that has received complaints and should have been repaired over a month ago.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? This is a well-traveled street and by the size of the damage there must be numerous complaints
made about it. I know someone who lives close to this area and was told it has been in poor condition for well over a month.
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. There were no other vehicles involved, no injuries to self or others. Incident was not caused by any type of driving violation.
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:
Richard H. Rowan Public Safety Training Center, 600 Lafayette Rd.
What would you like to see happen to resolve this claim to your satisfaction? Be reimbursed for the cost of tire, lost wage and towing expense.
Were there witnesses to this incident? No. </w:t></w:r><w:r w:rsidRPr= 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: 2006 </w: </w:t></w:r><w:r Make: Ford </w:t></w:r></w:sdt Model: Fusion </w:t></w:r></w:sdtConte Color: Dark Grey
License Plate #: JNP226 </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidRPr="003 </w:t></w:r><w:r wState vehicle is registered in: MN
Registered owner of vehicle: Timothy Dennis Conley Driver: Timothy Dennis Conley
Area(s) damaged: Left Front Tire.
If a City vehicle was involved, License Plate # </w:t></w:r></w:sdtCont </w:t></w:r><w:r w:rsidR="00Color: Click or tap here to enter text.
Was there City insignia on the vehicle? Choose an item. </w </w:t></w </w:t></w:r><w:rDriver’s Name: Click or tap here to enter text.
Other property damaged: Click or tap here to enter text.
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. </w:t></w:r><w:rWhere? Click or tap here to enter text.
Was medical treatment received? NO. </ </w:t></w:r><w:r w:rsidRPr="003033E3"><w:rPr>Where? Click or tap here to enter text.
First day of medical treatment? N/A </w:t></w:r><w:r w:rsidRPr="003033E3"><w:rPr><w:rFoAre you still receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES <
Employer(s): Reds Savoy Pizzeria in Woodbury
How much time have you missed from work? I was 2 hours late for work due to incident.
If you are submitting other documents, please state what you are attaching and how many pages: Pictures of tire damage, repair cost, towing charge, pothole, and area where incident
occurred.
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: Timothy Dennis Conley <
Signature of Person submitting this form: Timothy Dennis Conley
Relationship of person signing to Party making the claim: SELF
Date document is being signed: 4/9/2023
Revised March 2023