Ali 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
gover•ning body of the municipaliry 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 answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, S IN PAUL, MN 55102
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First Name I�'�� ' Y 1 � Middle Initial Last Name D C�C I V E D
Company or Business Name 201�
Are You an Insurance Comp � Yes/ io If Yes,Claim Number?
Street Address����+ �G`'U� ���--4'��� ` ��'�`-�'e-'� CITY CLERK
) �'1l r-�N��� 51�►- 9 9 9 �'
City�jr� �+ ��`- �— State Zip Code (�7�l.J 17C�'�'�Sfi C
Daytime Phone�) )�I -V�Cell Phone( ) - Evening Telephone( ) -
Date of Accidend Injury ar Date Discovered��2�" I � �� Time � am/�
Please state,in detail, what occurred(happened),and why you are submitting a claim.Please i�icat why or how ou / �
f 1 the City of Saint Paul ar its employees are involved and/or respon ible for our d�ages.�� I/���]_�_,T�L�
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Please check the box(es)that most closely represent the reason for completing this form:
� My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed �was injured on City property
❑ Other type of property damage-plea�e specify • �'Fr
`�-Other type of'njury-�lease spe ify I'1�SU�v�� �► �-i �C�;S��< i ccs �c�-�
.�,Q1s� d�e�l-c��� 1�►^�•�1��.if�r- I P�-r-�-S.�-;:�.ti
In order to process your claim you need to include copies of�l applicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds$500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2-Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims— lease com lete this section
Were there witnesses to the incident? Yes No Unkno (circle)
Provide their names, addresses and telephone numbers:. S l� �—,� S '�� `S �'`"�-
�v-��v� (�c�sz w r�s AC��s-1� s�,�--e_ �-}�,rr e. v� � �s�� F� ��' .
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Were the police ar law enforcement c led? Yes No nknown 2 (c,}r�e) (�_2.��� '
If yes, what department or agency? ���^S�� ��S- Case#ar report# � C
Where did the accident ar injury take place? Provide street address,cross street,intersection,name of ark or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. � �M�NN�����--
Please indicate the amo t you are seeki in compensation or wha ou would like the City to o to resolve this claim
to o r satisfac ion.� d�� ' �S��•� c� 1� ���v
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Vehicle Claims—please complete this section ❑ check box if this section does not apqlv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims— lease com lete this ection ❑ check box if this section does not a 1
�w were you injured? �A S ��C.-�-C ��` (�-'�' S 2� t�'Cl�o- C.�L
'�.Ar�SI� G. v � P f�S O...i t�G � !C'S' �''1S Ul.i�/J'
What part(s)of your body were injured? �^- s
Have you sought medical treatment? Yes � Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss wark? (provide date(s))
Name of your Employer:
Address Telephone
heck here if you are attaching more pages to this claim form. Number of additional page� � .
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By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed ��"t'�"`-'' , ` � ZUl�
Print the Name of the Person who Completed this Form: 1 �'M��' ����lL` ���
Signature of Person Making the Claim: '
Revised February 2011 ,
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Affidavit of Nationality
I, Tamir Malik Ali, a man abiding on the lands of Northwest Amexem i,e AI Moroc, being part
and parcel to the United States of America Republic via the Great Seal, do hereby declare my
nationality as FREE INDIGENOUS ABORIGNAL MOABITE (MOOR).
Any claim or information to the contrary is hereby estopped.
.
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Tamir Malik Ali
In Propria Persona �,
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To: St.Paul Claims Department
From: Tamir Malik Ali f.k.a Corey Statham
Re:Citation#900300023412 Case#62-CR-14-2291
Date April 14, 2014
All public officials are under Motu Proprio as of September 1, 2013. Quasi-Civilians and Quasi
, Civilian Authorities, laws are suspended. All existing civil laws, Roman law or Statutory law is for
colonist/civilians only. United States Corporation is dissolved and all States are subject to this
Promulgation memorandum, not to operate civil process, nor coerce Aboriginal Indigenous to '.
Civil Process. Civi) Process is FRAUD MISREPRESENTAION; title 15 U.S.C.
The charges alleged against my person are fraudulent and based on Roman Civil Process(s) '
Color of Law.
I am not a U.S. citizen but a free Indigenous Aboriginal Moabite (Moor) part and parcel to the
United States of America Republic.
The citation 900300023412 is without "corpus delicti" and is injurious to my unalienable rights,
liberties and pursuit(s) of happiness.
The state/city does not have my consent in this matter, nor do they have jurisdiction over the
sovereign man.
I Tamir Malik Ali (f.k.a) Corey Statham do not have a contract with the city whereby I agreed to
do or not do ANYTHING.
The injuries caused by the city are;
1. Assault and Battery
2. Tresspass
3. Harrasment
4. Fraud/Mail
5. Extortion
U.S.C. 18 §242 Deprivation of Rights Under Color of law: Whoever, under color of any law,
statute, ordinance, regulation or custom, willfully subjects any person in any State the
deprivation of any rights shall be fined under this title or imprisoned not more than one year, or
both.
U.S.C. 42 §1983 Every person who, under color of any statute, ordinance, regulation, custom, or
usage, of any State subjects, or causes to be subjected, any person within the jurisdiction
thereof to the deprivation of any rights, privileges, or immunities secured by the Constitution
and laws, shall be liable to the party injured in an action at law.
U.S.C. 42 §1986 Action for Neglect to prevent: Every person who, having knowledge that any of
the wrongs conspired to be done or are about to be committed, and having power to prevent
or aid in preventing the commission of the same, neglects or refuses so to do, if such wrongful
act be committed, shall be liable to the party injured.
U.S.C. 18 § 1341 Whoever, having devised or intending to devise any scheme or artifice to
defraud, or for obtaining money or property by means of false or fraudulent pretenses,
representations...or procure for unlawful use any...obligation, security, or other article, or
anything represented to be or intimated or held out to be such counterfeit or spurious article,
for the purpose of executing such scheme or artifice or attempting so to do, places in any post
office or authorized depository for mail matter, any matter or thing whatever to be sent or
delivered by the Postal Service...or knowingly causes to be delivered by mail or such carrier
according to the direction thereon, or at the place at which it is directed to be delivered by the
person to whom it is addressed, any such matter or thing, shall be fined under this title or
imprisoned not more than 20 years, or both.
U.S.C. 18 § 872 Whoever, being an officer, or employee of the United States or any department
or agency thereof, or representing himself to be or assuming to act as such, under color or
pretense of office or employment commits or attempts an act of extortion, shall be fined under
this title or imprisoned not more than three years, or both; but if the amount so extorted or
demanded does not exceed $1,000, he shall be fined under this title or imprisoned not more
than one year, or both.
"No action can be taken against a sovereign in the non-constitutional courts of either the United
States or the State courts and any action is considered the crime of earratry. earratry is an
offense at common law." State v Batson 17 S.E.2d 511. 512,513
Regards
�
Ta ir Malik Ali Mailing Address:
In Propria Persona Tamir Malik Ali f.k.a. Corey Statham
Sui luris Saint Paul General Delivery
All Liberties Reserved Saint Paul Minnesota
{55101-9998} Non Domestic
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� MAILED FROM ZIPCC,DE 55' �7�
COREY STACEY STATHAM
435 UNNERSITY AVE E
ST PAUL MN 55101
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