Distad, Danielle
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
mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint 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: __DANIELLE_________________________ Last Name: __________DISTAD___________________________
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? 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: __89 GOEGE STREET EAST _____________________________________________________________________________________________
City: SAINT PAUL______________________________ State: __MINNESOTA____________ Zip Code: _55107__________________
Daytime/Work Phone: _____6518083776_________ Cell Phone: ____6518083776_________________________________________
Date of Incident or Date Discovered (Must Complete): _____________________________ Time: _____________________________
12/12/2025 4:30 PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___I HIT A POTHOLE ON MY WAY TO WORK AND MY TIRE INSTANLTY POPPED_________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __THIS POTHOLE HAS BEEN FILLED NUMEROUS TIMES, BUT TURN BACK INTO A POTHOLE IMMIDIALTY. IT IS
COLD, SO NO POTHOLES ARE BEING FILLED. HOWEVER, ITS BEEN DAYS AND THERE ISNT EVEN A WARNING OR CONES TO DETURE OTHER PEOPLE FROM HITTING THE POTHOLE__________________________________
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.
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? __I DI NOT MAKE A POLICE REPORT BUT I DID CALL NON EMERGENCY RIGHT AWAY TO ASK WHAT I COULD DO NEXT __________________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
_______WEST 7TH SRTEET AND ERIE STREET ON THE BIRDGE THAT GOES TO WEST 7TH SRTEET AND ST.CLAIRE_____________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? __I WOULD LIKE A WARNING TO OTHERS THAT THE POTHOLE IS THERE UNTIL IT CAN BE FILLED, I WOULD ALSO LIKE TO
BE REIMBURSED FOR THE COST OF A NEW TIRE._________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent><w:sdtEndPr><w:rPr><w:rFonts w:cs="Calibri" w __MY TWO CHILDREN AGED
8 AND 11 WERE IN THE CAR WHEN THIS HAPPENED, WE PULLED INTO THE MARATHON GAS STATION THAT HAS CAMERAS THAT WOULD SHOW ME CHANGING THE TIRE ON THE CAR TO A DONUT IN NEGATIVE WEATHER____________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2019______ Make: ___FORD____ Model: __FUSION_______ Color: __SILVER__________
License Plate #: _____HZW659____________________ State vehicle is registered in: MINNESOTA_____________________
Registered owner of vehicle: ___DANIELLE DISTAD ________ Driver: __DANIELLE DISTAD_________________________
Area(s) damaged:__FRONT DRIVER SIDE TIRE_______________________________________________________________
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? YES / NO Driver’s Name</w: ______________________________________________________
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? ______________NONE___________________________________________________
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? YES / NO
Did you miss any work as result of this incident? YES <
Employer(s): _______SLAVIK ENTERPRISES INC I WAS TWO HOURS LATE FROM CHANGING THE TIRE ____________________________
How much time have you missed from work? ________2 HOURS_________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: _____I AM ATTACHING 4 PHOTOS, ONE OF MY CALL LOG TO THE NON EMERGENCY AND ALSO THE STATE
TO REPORT THE HOLE, THE BILL FOR GETTING A NEW TIRE,AND 3 PHOTOS OF THE POTHOLE STILL THERE ON 12-14-2025____________________
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: _______________DANIELLE DISTAD ______________________________________________ <
Signature of Person submitting this form: __________DANIELLE DISTAD_____________________________________________
Relationship of person signing to Party making the claim: _______________________12-15-2025___________________
Date document is being signed: _____________________
Revised March 2023