Shannon, Erica
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 is to the Saint Paul
https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may <
mailto:cityclerk@ci.stpaul.mn.usemail, fax (651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”
Individuals: First Name __Erica __________________________ Last Name ______Shannon_________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☒ He/Him/His <☐_ They/ Them/Theirs ☐
Company or Business Name: ______NA________________________________________________________________________
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, then provide your Insured’s/ Client’s Name ____________________________________________________________
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Street Address: 345 Cedar St 210___________________________________________________________________________
City: ________________St Paul____________________________ State ____Minnesota_______________ Zip Code 55101___
Daytime/Work Phone _______________________________ Cell Phone ________651-447-1205__________________________
Date of Incident or Date Discovered (Must complete) 12/21/2022Time _________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. My daughter and I have suffered emotional torture for months due to a fraudulent eviction in
the Ramsey County Court. Despite my multiple attempts to provide evidence that Press House was lying about my unpaid balance, and even documents from Rent Help MN admitting there was
some type of accounting issue with my case, The Ramsey County District court denied every motion I filed. Judge Patrick C Diamond and Kathryn Bergstrom conspired to use escrow as a tool
to silence me, and further prolong my anguish despite me expressing my mental state numerous times in court documents. I believe these acts were racially motivated given a very brief
google search of Patrick C Diamond.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? This happened in a courthouse in St. Paul, and by people Press House is also located in St.
Paul, and operates under section 42 funding. Several people knew this was wrong, multiple city agencies failed me. the City of Saint Paul has allowed its judges to act well beyond rules
of reason without consequence.______________________________
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.
Case no 62-hg-cv-22-3292
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 ____________________
Revised December 2021
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.
</w:t></w:r345 cedar st, St. Paul MN 55101____________________________________________________________________________________
Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your satisfaction? __Maximum Financial compensation applicable, Jail time for those who committed fraud. Especially IVON CAMACHO_______________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. No witnesses, but there is a well documented court record 62 Hg-cv-22-3292 ______________________________
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 </w_____________________________________________
Other property damaged: ___________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _Mental well being deteriorated. I suffered suicidal ideation, and long bouts of depression. I had many panic attacks, and experience depersonalization
due to trauma and harassment. _________________________________________________________________________
Did you go to the emergency room or urgent care? NO Where? _________________________________________________
Was medical treatment received? YES Where? </_____Associated Clinic of Psychology_________________________________
First day of medical treatment? 11/14/2022 Are you still receiving medical treatment? YES
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. ______________________
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: __Erica Shannon______________________________________________ <
_______________________________________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: ___________________
Date document is being signed 3/16/2023
Revised December 2021