Horn, Hannah
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: __________Hannah______________________ Last Name: Horn_______________________________________________
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: _____1649 Arlington Ave. E__________________________________________________________________________________________
City: ____________________St. Paul__________________________ State: ______MN__________________ Zip Code: _____55106______________
Daytime/Work Phone: __________________________________ Cell Phone: _______651-724-4122______________________________________
Date of Incident or Date Discovered (Must Complete): 7/9/2023 Time: _____Morning________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ________There are two significant potholes located on E Shore Dr. south of Larpenteur Ave that
I hit while driving South on E Shore Dr. I immediately heard noises when accelerating and turning my vehicle after hitting these potholes. I brought my vehicle into a mechanic on 7/11
and was told that my front wheel bearings were damaged on both sides and needs replacements due to the damage from the potholes. ____________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _______________________These two potholes have not been repaired at all this spring/summer and
are significantly deep, almost 4-5 inches deep in places. In order to avoid them, one would have to not maintain correct lane position, which always presents a possible safety issue.
____________
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:
_____________________________________________E Shore Dr. and Larpenteur Ave. The potholes are located south of Larpenteur._______________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? __________________________________________Reimbursement for my car repairs due to the potholes. __________________________________________________________________
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________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: __2017_______ Make: Ford Model: Escape Color: Black
License Plate #: _______362 XUB__________________ State vehicle is registered in: ___________MN________________
Registered owner of vehicle: _______Hannah Horn______________________ Driver: Hannah Horn
Area(s) damaged:____front wheel bearings, both sides__________________________________________________________________________________
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: _____bill 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: ____________Hannah Horn_________________________________________________ <
Signature of Person submitting this form: Hannah Horn
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 7/19/2023
Revised March 2023