LeVoir, CharlesRevised March 2023
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 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: Charles Last Name: _____LeVoir__________________________________________
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? 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: _______________________________________________________________________
Street Address: 7675 Iverson Ave S Cottage Grove, MN 55016
City: Cottage Grove State: ___________MN_____________ Zip Code: ____55016_______________
Daytime/Work Phone: 952-278-0556 Cell Phone: 6513538229
Date of Incident or Date Discovered (Must Complete): 3/5/2023 Time: _________5pm (approx.)____________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __________hit a huge, unavoidable pot
hole on Como Ave__________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Front right tire immediately lost all air and
pressure and a tow was needed to get the car home
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.
Revised March 2023
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? YES / NO
If yes, please provide the police report case number: No
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:
_____________________________________________Como Ave and Raymond
Ave_______________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
Full reimbursement of repair costs
Were there witnesses to this incident? Please provide names and contact phone numbers:
___________________________Phoebe LeVoir 651-417-
8118_________________________________________________________________________________
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: ______________________________________________________
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: This form and two documents
proving repair costs paid
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: _________________________Charles LeVoir____________________________________
Revised March 2023
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: ______Self____________________________________
Date document is being signed: 4/1/2024