Hanks, Nick
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: ______Nick __________________________ Last Name: ______________________Hanks_________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: __________N/A__________________________________________________________________________
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? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
</
Street Address: 5729 42nd Ave. S____________________________________________________________________________________
City: minneapolis State: Minnesota Zip Code: 55417
Daytime/Work Phone: ____320-761-1584______________________________ Cell Phone: 320-761-1584_
Date of Incident or Date Discovered (Must Complete): 3/18/2026 Time: _____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___Driving eastbound on West. 7th at 8:55 in the morning, my Nissan Sentra drove over a huge
pothole between E. Maynard Drive and Alton ST. The hole was slightly hidden by a fresh covering of snow in the east bound lane and upon hitting the pothole my front right car tire was
destroyed at impact. In addition to rendering the tire completely totaled, I was required to reschedule more than 2 hours of scheduled advocacy at the Capitol._________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Assuming the pothole was a known commodity--- it’s presence and the impact on my vehicle+ work
loss should be covered – based on the inability to keep up the tax support public road ways.________________
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? ____________________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
West 7th (MN -5) between E. Maynard and Alton St.(______________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? I would like 1.) The Hole Fixed 2.) Compensation for the New Tire Cost (See attached fee) + 3.) Potential
Compensation for 2 billable hours @$50 to be recouped.____Total for Tire (1/4 of Total Bill attached) + 100$ in Billable work hours.___________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 _______________________________________AAA-
Came as to support the tire replacement.__They met me on Benson Ave. where I was able to safely pull the car over. Additionally my Partner Kati Griffin (651-442-1273)__ responded to
help me connect with AAA_______________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ______2018___ Make: ___________Nissan ______ Model: Sentra Color: Gray
License Plate #: Kaj810 State vehicle is registered in: ________Minnesota___________________
Registered owner of vehicle: ____________Nick Hanks_________________ Driver: Nick hanks
Area(s) damaged:Right Front 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? _____________________________________________________________________________
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: _________________________
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: ___________Nick Hanks__________________________________________________ <
Signature of Person submitting this form: ____Nick Hanks___________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 3/19/2026
Revised March 2023