Carlson, JoleenNOTICE 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: ___Joleen______________________ Last Name: ______Carlson_____________________________________
Please Indicate Your Pronouns: x She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ____St Paul Regional Water_____________________________________________________________
Is this claim being made by an Insurance Company? X NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an Attorney? X NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: _____883 Lakeview Ave___________________________________________________________________________
City: ______St Paul__________________________________ State: ______MN________________ Zip Code: __55117___________
Daytime/Work Phone: ____612-308-3840___________________ Cell Phone: _______612-308-3840__________________________
Date of Incident or Date Discovered (Must Complete): _____March 7, 2025________________________ Time: ______________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ____
St Paul Regional Water replaced a fire hydrant near our sprinkler system. Today we had Rain Master over to check and turn on the
system. They found that the head of that sprinkler was damaged and I called St Paul Regional Water. I told them I wanted them to
fix it or reimburse me for $75 to have it repaired right then. I was told not to repair it and that I would get a call back later that
afternoon or tomorrow. I told the repair guy not to fix it and he left. I got a call back 10 minutes later saying that it is in the
boulevard and won't be fixed. I disagree with this, as we are responsible for caring for the land in the boulevard and had I known
that I could have fixed it for less. It will now cost $175 to fix because Rain Master will have to make another trip to do it and will
charge for that.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _______St Paul Regional Water damagd the
sprinkler head ____________
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.
Revised March 2023
X 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? X 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:
883 Lakeview Ave, St Paul MN 55117 a few houses down from the intersection of Lakeview and
Victoria____________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
______I want St Paul Regional Water to pay $175 to fix a sprinkler head they damaged or have them fix it
themselves._______________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
_______our household could see the workers doing their work, picture included, but we were not close enough to see it be
damaged, that would have interfered with their work. __________________________________________________________
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: _________________________
Revised March 2023
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: _____Joleen Carlson and Chris Luhman_______________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: ________occupants of property__________________________________
Date document is being signed: ____4/28/25_________________
Revised March 2023