Peterson, Lisa (9.5)Revised 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: Lisa________________________ Last Name:Peterson Click or tap here to enter text.
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? _________________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: _______________________________________________________________________________________________
City: ______________________________________________ State: ________________________ Zip Code: ___________________
Daytime/Work Phone: __________________________________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): July 28, 2026 Time: 9:30 p.m.
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I was visiting friends at 1411 Palace Ave in
St. Paul on the evening of July 28. A gust of wind came up and we heard a loud noise. Looked out front and a tree limb had fallen on
my car.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? As stated by a number of surrounding
neighbors, the city had just been to this street for easement tree trimming. They chose to leave this rotting tree standing. It had
many bare/dead limbs and as you’ll see in photos, the trunk was deeply rotted.
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: ___________________________
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:
1411 Palace Ave 55105
What would you like to see happen to resolve this claim to your satisfaction? I would like to be made whole. Due to the age of the
car the original estimate for damage would have totaled the car and I am on a limited fixed income so I had to pick minimal repairs.
I would like to complete repairs and be reimbursed for my deductible. Amount for repair $2,611.29 plus deductible $500. Total
$3,111.29.
Revised March 2023 Were there witnesses to this incident? Please provide names and contact phone numbers: Many neighbors.
Revised March 2023
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2010 Make: Toyota Model: Matrix Color: Silver
License Plate #: BRK106 at the time of damage RWF 978 currently State vehicle is registered in: MN
Registered owner of vehicle: Lisa Peterson Driver: Lisa Peterson
Area(s) damaged:Hatchback, roof, passenger side mirror
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: Photos of damage and repairs
still needed (14) complete repair estimate (3 pgs) completed repair (2pgs) 19 total
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: Lisa Peterson
Signature of Person submitting this form: Lisa Peterson
Relationship of person signing to Party making the claim: self
Date document is being signed: September 5, 2025