Taye, Nathnael
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: Nathnael </w:t></w:r><w:r Last Name: Taye
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? NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: 4407 N Humboldt Ave N Apt 102
City: Minneapolis State: MN Zip Code: 55412
Daytime/Work Phone: 651-675-8041 Cell Phone: 651-675-8041_
Date of Incident or Date Discovered (Must Complete): 7/17/2024 Time: 3:30pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: On 7/17/2024, at approximately 3:30, I was driving my vehicle, a 2018 Chevy Malibu, along the
intersection of Phalen Boulevard and Johnson Parkway in East Saint Paul. During my drive, I encountered a section of the road that had been recently painted with yellow traffic paint.
There were no visible signs or barriers indicating that the paint was wet and that drivers should avoid the area. As a result, I inadvertently drove over the freshly applied yellow paint.
The wet paint splattered onto the side of my car, the tires, and the tire splash shield. Despite my efforts to remove the paint, it has adhered firmly and is not coming off with standard
cleaning methods. This has caused significant damage to the exterior appearance of my vehicle and the affected parts.Damages:- Yellow paint on the side of the car- Yellow paint on the
tires- Yellow paint on the tire splash shieldThe paint is not removable through conventional cleaning methods, causing permanent damage to my vehicle's aesthetic and requiring professional
cleaning or replacement of the affected parts.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I believe the City of Saint Paul is responsible for the damages to my vehicle due to the following
reasons:Lack of Proper Signage: There were no visible signs or barriers indicating that the road had been freshly painted and that the paint was still wet. Proper warnings would have
prevented this incident.Duty of Care: The city failed to maintain safe road conditions by not marking the freshly painted area, leading to the damage of my vehicle.Preventable Damage:
The absence of adequate warnings directly caused the paint to adhere to my car, which could have been avoided with proper signage. As a result, I seek compensation for the costs incurred
to restore my vehicle to its original condition.
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:
Intersection of Phalen Boulevard and Johnson Parkway in East Saint Paul
What would you like to see happen to resolve this claim to your satisfaction? To resolve this claim to my satisfaction, I would like the City of Saint Paul to cover the full cost of
repairing the damage to my vehicle caused by the wet paint. This includes reimbursement for the costs outlined in the two estimates for repairs.
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 N/A
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2018 Make: Chevy Model: Malibu Color: Black
License Plate #: ZBZ003 State vehicle is registered in: Minnesota
Registered owner of vehicle: Nathnael Taye Driver: Nathnael Taye
Area(s) damaged: Yellow paint on the side of the car, on the tires, and on the tire splash shield
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? 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: Images of damage to car (2-3 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: Nathnael Taye <
Signature of Person submitting this form: Nathnael Taye
Relationship of person signing to Party making the claim: Myself
Date document is being signed: 7/26/2024
Revised March 2023