Statham 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 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 ezplain 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, SAINT PAUL, MN 55102
First Nam����� Middle Initial Last Name�C:.J��:,VY�-
Company or Business Name �
R��i���e,��
Are You an Ins ance Company? Yes/ o If Yes, Claim Number?
Street Address�• L ��� �' � �-�' AIIG � 1 20�
f�� ^ C �-� ! �'�" � �4,4
City ���-�'%�� � State � ' I ���i��(r-'ZipCode �_.� :_-�--��
Daytime Phone �J� �-����Cell Phone (_) - Evening Telephone L� -
Date of Accident/Injury or Date Discovered � � Time • ✓�% �ip1�pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate wh or how ou
the City ofnSaint Paul or its employees a�inv lved and/or responsible for your damages. � �
� ;�i �i c�:. ���v y� � � v c�n � � ;�. ��;. � ` � C�1 �'X� �C� v, v
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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—please specify _ ��������1
�'� J
�Other type of injury—please specify\I 1�1��,{i`�Y� � � n'''�'� ' � ��
In order to process your claim vou need to include copies of all anplicable 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 encouragec�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 dam3ged 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-please complete this section
Were there witnesses to the incident? es No Unlrnown (circle) �
Provide their names,addresses and telephone numbers: �. w v� ��2 w �� ��L `�
�.2� w� 2.� � :��..�,.'1 C�.ti'"'� ,�G.7UC.e c� l ��(}.�._ c-Q-►-�L
Were the police or law enforcement called? e � o Unknown (circle)
If yes,what department or agency?�� i N^ � . �� Case#or report#
C� a'l.c..N.a..�..-� ����2J?S`
Where did the accident or injury take p ace? Provide street address,cross street,intersection,name of park or facility,
cl est landmark, et� Please be as detailed as possible. .If nec�ssary a h a diagram. �1�U��`�l'�
�c.�m t c. �,;� �I��K �,� -� �.�...�. � �a
Please indicate the amount you are seeki in compensation or what you would like the �ty to dg,to resolve this`laim
to your satisfaction. ��25�- ' �2.,5 ` �^ C � n �'�Lv�.r�
1..7 ' 1 �jSC;
Vehicle Claims-please comelete this section ��check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number Sta.te Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Nuxnber State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims- lease com ete this s ction ❑ check box � this section does not a 1
Ho�v were you injured? � � � 1 u2� ��. ' �S�E 1-L 'u..►�.
4 Li� ' � �w ;,��S t� U c^ L�V , .,, � - ` - v�,�,�
What part(s) of your body were injured? l� 1 S�I-�S' �rv� w . S
Have you sought medical treatment? Yes No anning to Seek Treatmen 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 o
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
heck here if you are attaching more pages to this claim form. Number of additional pages�.
�,�-
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.
�� � � o� 12
Submitting a false claim can result in prosecution. Date orm was completed�' � �`� C
Print the Name of the Person who Complet this FQrm. '���� ���- \ �v�...
Signature of Person Making the Claim: � '"
.��--�j��S �(L.,2_�:`�-��--L �.-��C� �� J ^���-�
Revised February 2011
STATE OF MINNESOTA 2�d District Court
County of Ramsey Case Type:Civil
AFFIDAVIT OF TRUTH
STATE OF MINNESOTA )
COUNTY OF RAMSEY )
I, Corey Statham, hereinafter"Affiant" being sworn, state that I am at least 18 years of age and of sound
mind state and have first-hand knowledge of the facts contained herein, I state that the following facts
are true, correct and complete, presented in good faith and under penalty of perjury.
1. I understand and stipulate freely and with specifically that I am a living soul and sign as such so
that no mistake is made between the living soul and the corporation, COREY STATHAM.
2. On August 22"d 2012 at approximately 7:30am,three (3) Saint Paul Police Officers responded to
the Mounds Park Scenic Overlook.
3. There were no injured parties.
4. A felony was not in progress.
5. A misdemeanor was not in progress.
6. When the officers approached the affiant's automobile, the affiant was sleeping.
7. The Affiant is not aware of any Laws, Statutes or Ordinances that prohibit sleeping in an
automobile in a public park during hours of operation.
8. The park rules are posted at the park's entrance that clearly state no prohibitions against
sleeping in ones' automobile.
9. Officer 1 knocked on the affiant's window and asked for identification.
10. The affiant gave the officer prima facie identification/evidence that reserved all rights under
UCC1-308 w/o prejudice.
11. The officers 1, 2 and 3 compelled performance resulting in damages to the affiant.
t ; ' �
1;'
Further your Affiant Sayeth Not
, Signature
Print Name ✓�--
AddressQ� � � " �
City/State/Zip • � �— �5 ���
Phone��) � �U
Subsrci ed an sworn to bef re me
�i �d y o 2012.
� - - ��.�5�"�A BLAClC
Notary Public/Court Clerk
Notary Public by virtue of
Minnesota Statute 358.43
Please state, in detail, what occurred (happened), and whv vou are
submittin� a claim Please indicate whv or how vou feel the Citv of Saint
Paul or its emplovees are involved and/or responsible for your damages.
On August 215t 2012, at approximately 7:30am I, Corey Statham (claimant) was
relaxing in my automobile at the scenic overlook at Mounds Park. I apparently fell
asleep while relaxing. I was awaken by 3 Saint Paul Police Officers. Officer 1
initiated contact with me by knocking on the drivers' side window.
After being awakened by the knock, I asked what the problem was. Officer 1
responded by asking for ldentification. I presented identification that clearly
reserves all rights under common law. The officer compelled performance which
resulted in injuries/damages.
Officers 1 & 2 compelled me to exit the automobile. The officers then used force
to place my hands into handcuffs. As I continually stated that I wished not to
contract and that I do not consent, Officer 1 said "this is not a contract." After
being put into hand cuffs, I repeatedly kept saying to the officers that I do not
consent, then officer 3 walked up closely and pointed her taser at me.
Officer 3 then compelled me to walk to her police vehicle, she stated, "this is a i
contract" and placed me into the back seat of the squad car. As I sat in the back �'
seat, the three officers searched my automobile. I saw a lady approach from the '�
row of houses approximately 80 yards away and began to speak with officer 3. As
she spoke with officer 3, I repeatedly asked officer 1 & 2 "who is the injured
party?" and "what is the crime?" They did not respond.
After approximately 10 minutes, officer 3 returned to the squad car and sat in the
front. I asked her who is the victim? She responded by saying, "an anonymous
caller." However she did not tell me what the crime/charge was. After a brief �
conversation with officer 3, I was released from the back of the squad car and the
handcuffs were removed by officer 2. No citation was issued and I was apparently
free to leave.
I am submitting this claim because I believe that the 3 Saint Paul Police Officers
Nicole Rasmussen, Laura Bolduan and Tanya Tamm all conspired to violate my
common law rights, by acting outside their official capacity.
I believe the Saint Paul Police are involved and responsible because they
responded to a false report under Saint Paul City Municipal Code. Also, after they
arrived at the scene the claimant verbally expressed he wished not to contract
and verbally expressed that he does offer conset. The claimant also presented
prima facie evidence/Identification that rebuffed all presumptions of an implied
contract. Therefore, based on these facts, the claimant believes that the City of
Saint Paul is responsible for damages incurred.
Officer 1: Nicole Rasmussen
Officer 2: Laura Bolduan
Officer 3: Tanya Tamm
��
i
i
Dama�es/Iniuries
All Dama�es were conspired
1. False Arrest
2. Harassment
3. Illegal search and seizure
4. Invasion of privacy
5. Threat to inflict bodily harm (taser)
6. Negligence
NAME:Auorix Statham ADd�ESS PiCTU
F�ARTH STATUS: LIVING SOUL
, 81RTHDATE: 10-24-71
' '' Mt iNA GALA9(Y
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�'RUTH STA EMEN
THE BELOW SIGNED IS A FRIENDLY ALIEN
; OF TH� UNITED STATES
ALL RIGHTS I�ESERVED UNDER
-UCC1-308 W/O P JUD�CE
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