Notice of Claim Form -Luis A Iglesias Castro 1892 Hawthorne Ave E.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: _Luis Alberto_________________ Last Name: __Iglesias Castro____________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, X He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ____________________________________________________________________________________
Is this claim being made by an Insurance Company? YES / X NO If yes, what is your Claim/File Number? ____________________
Is this claim being made by an Attorney? YES / X NO If yes, what is your File Number? _____________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ____1892 Hawthorne Ave. E______________________________________________________________
City: __________Saint Paul_________________________State: ______MN__________________ Zip Code: __55119__________
Daytime/Work Phone: ______763-762-2300, from 3 to 11 pm___Cell Phone: ________612-325-2245__________________________
Date of Incident or Date Discovered (Must Complete): ___June 16, 2024_________Time: _From 5:30 to 12:00 pm_______________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:Damages caused by Police Armor Vehicle. I
included photos with this form and the Police took photos also.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The armor vehicle used during the
intervention weighs between 5 to 10 tons, it is too heavy to be driven into someone's property without expecting to cause no
damages. The Saint Paul Police Department was trying to arrest the person who lives next to my house, who was hiding in his
garage. I have nothing to do with the incident and I do not know why they parked the vehicle there, when they have 2 other points of
entry to the garage to apprehend the suspect. The Saint Police Department failed to take proper care while performing their duties
when they did not take into consideration that the concrete surface is not made to handle the weight of the armor vehicle,
causing the damages to my property.
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.
X 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.
Revised March 2023
This section must be completed for all claims.
Is there a police report for this incident? X YES / NO
If yes, please provide the police report case number: ___24-108-448________________________
If yes, what law enforcement agency responded? ______Saint Paul Police Department__________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
In the backyard of my house located at 1892 Hawthorne Ave. East, Saint Paul 55119
What would you like to see happen to resolve this claim to your satisfaction?
I would like that the concrete that was damaged get repaired and that the ground and grass that was damaged by the armor vehicle
tires get level like it was, so I can mow the grass without any risk of falling. I am a disabled veteran. If your office has contractors that
can do quality work and are less expensive than the contractors that gave me their estimates, I do not mind going with them, as long
the repairs get done in a promptly manner and well.
Were there witnesses to this incident? Please provide names and contact phone numbers:
Yes, Police Officer Nathan Kinn, Cell 651-703-6922__Desk 651-291-1111__Officer Kinn took photos and showed me the damages.
Then Officer Kinn informed me that the Saint Paul Police Department will be responsible for the damages to my property. Officer
Kinn texted me a link so I can fill out this form.
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 #: _________________________________ 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? _____________________________________________________________________________
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: _Estimates and photos___
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: __Luis Alberto Iglesias Castro __________________
Signature of Person submitting this form: ________________________
Revised March 2023
Relationship of person signing to Party making the claim: _My self, the PropertyOwner________________________
Date document is being signed: _____June 28, 2024.__________________________________________________
Revised March 2023