Kaba, Cheick
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: Cheick Last Name: Kaba
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? Click or tap here to enter text.
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: _______________________________________________________________________
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Street Address: 11550 Foley BLVD NW
City: Coon Rapids State: Minnesota Zip Code: 55448
Daytime/Work Phone: Day Time Cell Phone: 651-354-4154
Date of Incident or Date Discovered (Must Complete): 4/1/2023 Time: 04/03/2021
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I was informed that I have the right to file a claim and the city may provide remiburmsent or
payment for the damges
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The poorly maintained roads are littered with large, difficult-to-avoid potholes. There is a
sizable one in the middle of each of the streets that surround the campus. I can say that I am not alone in feeling discouraged because many students have gone through similar things.
Few of them, however, are aware that they can submit a claim. I have huge dent and breakge in my front rim
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:
152-200 Flynn ST N Saint Paul
What would you like to see happen to resolve this claim to your satisfaction? I would like the damages of my car fixed and hopefull see the condtions of the roads better as they are
only getting worse
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 No
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2018 Make: Toyota Model: Corolla Color: Black
License Plate #: JLU-573 State vehicle is registered in: MN
Registered owner of vehicle: Cheick Kaba Driver: Cheick Kaba
Area(s) damaged: Front Rim and and front bumper
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? NO Driver’s Name</w: ______________________________________________________
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? No
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? / 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: I will go get an estiamte from an autobody repair shop then sumbit them
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: Cheick Kaba <
Signature of Person submitting this form: Cheick Kaba
Relationship of person signing to Party making the claim: N/A or Himself
Date document is being signed: 04/07/2023
Revised March 2023