Montague, Taymara
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: __________Taymara______________________ Last Name: Montague
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: _____Lutheran Social Service MN_______________________________________________________________________________
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: ____2485 Como Ave___________________________________________________________________________________________
City: St. Paul State: MN Zip Code: 55108
Daytime/Work Phone: _______612-554-6012___________________________ Cell Phone: 612-554-6012_
Date of Incident or Date Discovered (Must Complete): 7/21/2023 Time: __3:00pm___________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___On 7/21/2023 I noticed our storm drain was overflowing and filed a notice with the City of
St. Paul. As a result, Richard Ekobena emailed me and after some conversation/photos were exchanged, he informed me the drain issue was our (LSS MN) issue to address as the storm drain
is on our property. We had numerous contractors (4 total) look at the issue. Roto-Rooter attempted jetting the pipe on two separate occasions which were both unsuccessful. After emailing
Richard Ekobena again, I received a list of City Contractors as the question seemed to be was there a break in the pipe, was it profoundly obstructed, or blocked off. Because jetting
the pipe was unsuccessful (which is understandable now that we know the pipe was sealed off by workers with the City of St. Paul), we scheduled with Ground Tech, one of the City Contractors
on the list provided by Richard Ekobena, to have a vac truck clear the pipe so that we could get a camera into the drainpipe. Ground Tech determined that the pipe was sealed off after
clearing the pipe of debris and, after some conversation with City workers, the City sent another vac truck with a camera. During this process, part of the ground collapsed creating
a small sinkhole across the street at the junction where the storm drain and sewer pipe were supposed to connect. From there the city workers discovered that the storm drain and sewer
pipe sit at different levels and that the drainpipe was mistakenly considered abandoned and sealed off by city workers. This action is directly responsible for our storm drain backing
up and the resulting actions we took to clear it after being told the drain backup was our responsibility to clear.___________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __City workers directly caused the conditions that lead to our storm drain no longer functioning.
The city also knew about the problem 4 years prior to the event and took no action to remedy it. When we informed the city on 7/21/2023 of the issue, we were told the storm drain was
our responsibility to clear and, as a result, we contracted workers to have it cleared._________________________________
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:
__________2485 Como Ave., St. Paul, MN 55108__________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? ______All the related Roto-Rooter and Ground Tech bills to be paid in full. _____________________________________________________________________________________________________
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 _____________N/A_______________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _________ Make: _________________ Model: __________________ Color: __________________
License Plate #: _________________________ State vehicle is registered in: ___________________________
Registered owner of vehicle: _____________________________ Driver: __________________________________________
Area(s) damaged:______________________________________________________________________________________
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: __________2 Roto-Rooter bills, 1 Ground Tech Bill, and 3 email chains with Richard Ekobena_______________
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: __Taymara Montague___________________________________________________________ <
Signature of Person submitting this form: Taymara Montague
Relationship of person signing to Party making the claim: Facility Manager
Date document is being signed: 9/8/2023
Revised March 2023