Stuckey, CarlRevised March 2023
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 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: ____Carl____________________________ Last Name: _________________Stuckey
______________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: _______McCormick Law Firm
_____________________________________________________________________________
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 If yes, what is your File Number? __Tax ID 81-
3467344_____________________________________
If yes, provide your Insured’s/ Client’s Name: ___Carl Stuckey
____________________________________________________________________
Street Address: _________________________400 S Industrial Blvd Ste 200
______________________________________________________________________
City: ____________Eulss__________________________________ State: ___________TX_____________ Zip Code:
76040___________________
Daytime/Work Phone: _(713) 401-9027_________________________________ Cell Phone:
_____________________________________________
Date of Incident or Date Discovered (Must Complete): 8/1/2023 Time: ___12PM__________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __________Client was a passenger on the
Metro bus. Other party hit that bus__________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __Our client was a passenger on the
bus__________________________________
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.
Revised March 2023
☐ 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? YES
If yes, please provide the police report case number: ___Unk at this time________________________
If yes, what law enforcement agency responded? ___St Paul
_________________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
_________________Unknown
___________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
Client would like compensation for his pain and suffering.
____________________________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
No witnesses
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _________ Make: _________________ Model: __________________ Color: __________________
License Plate #: _________________________ State vehicle is registered in: ___________________________
Registered owner of vehicle: _____________________________ Driver: __________________________________________
Area(s) damaged:______________________________________________________________________________________
If a City vehicle was involved, License Plate #: ______UNK ___________________________ Color:
_______________________________
Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________________________________________________
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _______Whole Back
______________________________________________________________________
Did you go to the emergency room or urgent care? YES Where? __Regions Hospital
_________________________________________________
Was medical treatment received? YES Where? _________Emergency Room
_______________________________________________________
First day of medical treatment? 8/1/2023 Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? YES / NO
Revised March 2023
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: _VaDaisha Wilson ____________________________________________________________
Signature of Person submitting this form: VaDaisha Wilson _______________________________________________________
Relationship of person signing to Party making the claim: ___Legal ______________________________________
Date document is being signed: 1/11/2024