Puckett, PatrickNOTICE 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: ____Patrick_______________________ Last Name: ___Puckett_____________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, X 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: __1539 Asbury St._____________________________________________________________
City: ___St. Paul___________________________ State: ___MN_____________________ Zip Code: __55108_________________
Daytime/Work Phone: __952-215-4691______________ Cell Phone: ______952-215-4691_________________________
Date of Incident or Date Discovered (Must Complete): 7/29/2024 Time: _____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: A Public Works contractor removed the
property iron installed by a registered land surveyor while repairing public sidewalk as part of their sidewalk program. The removals
cut into the yard more than anticipated. Once disturbed, the location and information was no longer valid. It was initially thought
that PW Surveyors could replace the iron with information from the original installing surveyor, but that turned out to not be true.
We learned this spring that I would have to fill out a claim form after getting an estimate from that original surveyor, which was up to
$300.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? It is a property marker we paid to have
installed that denotes private property, is on private property, and was removed by a Public Works contractor. The St. Paul Surveyors
office is unable to replace the property marker and suggested a claim form be filled out to have the original installer put it back in,
Lake and Land Surveying. Their quoted price was up to $300 to have it done. While the incident is more than 180 days since it
occurred, I was led to believe that Public Works could do the work until this spring.
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.
Revised March 2023
☐ 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? YES / NO No police call or report
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, intersection or name of city park or facility:
At my southeast property corner at 1539 Asbury St.
What would you like to see happen to resolve this claim to your satisfaction?
I would like Public Works to reimburse me for the cost charged by Lake and Land Surveying to reinstall the property iron since the PW
surveyors office cannot, which is a $250 charge.
Were there witnesses to this incident? Please provide names and contact phone numbers:
Tom Higbee, PW Inspector 651-356-1569
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: A picture of the site when the
forms were installed for pouring the concrete.
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: ___Ryan Lowry_________________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: _____________________
Revised March 2023
Property owners
6/12/2025
Revised March 2023