Webster, JaydenNOTICE 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: __________Jayden___________________ Last Name:
_______________Webster________________________
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? NO If yes, what is your Claim/File Number?
_________________________
Is this claim being made by an Attorney? NO If yes, what is your File Number?
_______________________________________
If yes, provide your Insured’s/ Client’s Name:
_______________________________________________________________________
Street Address: 3516 Roosevelt St Ne St Anthony 55418
City: St Anthony State: Minnesota Zip Code: 55418
Daytime/Work Phone: __________________________________ Cell Phone: 763-999-1159
Date of Incident or Date Discovered (Must Complete): 01-09-2026 Time: 11:10 PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:
While traveling southbound on Rice Street, just after crossing the intersection at Center Street, my vehicle struck a
large pothole in the roadway. The pothole was not clearly marked, barricaded, or visible prior to impact. The
incident occurred near 44.99702° N, 93.10595° W.
As a direct result of this roadway defect, my front passenger-side wheel rim was severely bent, rendering the vehicle
unsafe to drive and unable to hold air. The damage was significant enough that the wheel was not repairable and
required full replacement. Additionally, the force of the impact caused substantial damage to both rear shocks, which
were compromised and also required replacement.
All necessary repairs have since been completed, and the associated costs have been paid in full. This damage
occurred due to the hazardous condition of the roadway and the lack of adequate warning or maintenance, resulting
in unexpected and unavoidable vehicle damage for which reimbursement is being requested.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The City of Saint Paul is
responsible for maintaining its roadways in a reasonably safe condition for public travel. The pothole that caused
this damage constituted a hazardous street defect on a City-maintained roadway. The City either knew, or should
have known, of this condition through routine inspections and/or prior reports, yet failed to repair the defect or
provide adequate warning within a reasonable time. This failure directly and proximately caused damage to my
vehicle.
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.
X 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.
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? 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:
Southbound Rice Street, immediately after crossing the intersection at Center Street,
Saint Paul, MN
Approximate GPS location: 44.99702° N, 93.10595° W
What would you like to see happen to resolve this claim to your satisfaction?
Full reimbursement of all repair and replacement costs necessary to restore my vehicle to its condition prior to the
incident. This includes reimbursement for the replacement of the front passenger-side wheel rim and the replacement
of both rear shocks, along with all related parts, labor, taxes, and associated expenses directly resulting from the
hazardous roadway defect.
Were there witnesses to this incident? Please provide names and contact phone numbers:
No known witnesses.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2014 Make: Ford Model: Fusion Color: Silver
License Plate #: SHY-113 State vehicle is registered in: Minnesota
Registered owner of vehicle: Jayden Dale Webster Driver: Jayden Dale Webster
Area(s) damaged: Front passenger-side wheel/rim and rear suspension (both rear shocks)
If a City vehicle was involved, License Plate #: _________________________________ Color:
_______________________________
Was there City insignia on the vehicle? 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? NO Where?
___________________________________________________
Was medical treatment received? NO Where?
________________________________________________________________
First day of medical treatment? _____________ Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? NO
Employer(s):
_____________________________________________________________________________________________
____
How much time have you missed from work?
_____________________________________________________________________
Photographs of the pothole and damaged wheel/rim; paid repair invoices for wheel rim replacement and rear shock
replacement showing full repair costs. Total: 12 pages.
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: Jayden Dale Webster
Signature of Person submitting this form: Jayden Webster
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 01-20-2026