Wise, MichelleNOTICE 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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon
or other relief demanded.”
Please complete this form in its en1rety by clearly typing or prin1ng your answers to each ques1on. If you have addi1onal documenta1on, you may add those
documents to your submission. You will not be contacted by telephone unless clarifica1on is needed. The claim process for inves1ga1ons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sec1ons completed. Submission this completed form to the Saint 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: ____Michelle________________ Last Name: ________________Wise__________________________
Please Indicate Your Pronouns: X☐ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: _None / Self__________________________________________________________________
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 ALorney? YES / NO If yes, what is your File Number? ______________No_____________________
If yes, provide your Insured’s/ Client’s Name: ______________________N/A_____________________________________________
Street Address: ___236 Charles Avenue ______________________________________________________________________
City: _St Paul___________________________________ State: _____MN________________ Zip Code: _______55103______
DayWme/Work Phone: ____651-744-3829________________ Cell Phone: ______________________615-724-7409___________
Date of Incident or Date Discovered (Must Complete): _____June 17, 2023_____ Time: __________9:45pm____________
Please state, in detail, what happened that prompted you to file a NoWce of Claim Form: I accidentally hit the same pothole twice,
because I was going to McDonalds at night and I didn't see it. That pothole is so deep and because cars are parked on both sides of
the street, it is extremely difficult to go around it. It is off the intersecWon of Marion and Aurora, in the middle of the street.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _The pothole was so deep that my car got
damaged while driving into it.________
Please check the reason that most closely describes the reason for your submiBng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiLed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esWmates for repairs or actual bill that has been paid.
X☐ Automobile damage from a street defect or pothole: please provide two esWmates 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 Wcket (if available), receipt
from Impound Lot, and two esWmates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing Wcket (if available), receipt from Impound Lot, and two esWmates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two esWmates 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.
Revised March 2023
☐ You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
ConEnue to page 2 of NoEce of Claim Form. Failure to complete and return both pages will result in delays.
This secEon must be completed for all claims.
Is there a police report for this incident? NO
If yes, please provide the police report case number: ___________N/A________________
If yes, what law enforcement agency responded? __________N/A_______________________________________________
Where did the incident take place? Please provide a street address, intersecWon or name of city park or facility:
___________ It is off the intersecWon of Marion and Aurora, in the middle of the street._____________________________
What would you like to see happen to resolve this claim to your saWsfacWon?
___________________________I would be so grateful for the City of St Paul to pay for the repair of my car damage______
Were there witnesses to this incident? Please provide names and contact phone numbers:
________________________Laila Brown 651-248-2398____________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s informaWon: Year: _2009__ Make: __Madza__ Model: __CX9__ Color: __Black___
License Plate #: ______DZD 900__________ State vehicle is registered in: __Minnesota_________________
Registered owner of vehicle: ___Michelle Wise (Brown)_________ Driver: __Michelle Wise (Brown)__________________
Area(s) damaged:___Wheel area__________________________________________________________
If a City vehicle was involved, License Plate #: __________N/A____________________ Color: _________N/A___________________
Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________N/A___________________________________
Other property damaged: ______________________________None____________________________________________________
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 Where? _____________N/A_______________________________
Was medical treatment received? NO Where? ____________N/A_________________________________________________
First day of medical treatment? __N/A_______ Are you sWll receiving medical treatment? NO
Did you miss any work as result of this incident? NO
Employer(s): __________________________________________N/A_______________________________________________
How much Wme have you missed from work? ___________________None_____________________________________________
If you are submiBng other documents, please state what you are aKaching and how many pages: __2 pages; pothole picture + bill
from the mechanic__
Revised March 2023
By signing this form, you agree that all informaEon provided is true and correct to the best of your knowledge.
Please NOTE that submiBng a false or misleading claim can and will result in prosecuEon under Minnesota Statutes.
Name of Person compleWng form: __Michelle L. Wise_________________________________
Signature of Person submimng this form: _______Michelle L. Wise_________________
RelaWonship of person signing to Party making the claim: _____________Self______________________
Date document is being signed: __September 27, 2023_____________
Revised March 2023