Gatlin, DougNOTICE 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 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: Last Name:
Douglas Gatlin Jr
Please Indicate Your Pronouns: She/Her/Hers, He/Him/His, They/ Them/Theirs
He/Him/His
Company or Business Name:
N/A
Is this claim being made by an Insurance Company? If yes, what is your Claim/File Number?
No
Is this claim being made by an Attorney? If yes, what is your File Number?
No
If yes, provide your Insured’s/ Client’s Name:
N/A
Street Address:
N/A
City: State: Zip Code:
N/A
Daytime/Work Phone: Cell Phone: _
N/A
Date of Incident or Date Discovered (Must Complete): Time:
11/05/2016
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:
I was released from prison and just graduated Teen Challenge and attempted to get my property and
it was destroyed.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
Because you destroyed 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.
N/A
Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has
been paid.
N/A
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.
N/A
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.
N/A
Property damage: please provide two estimates for repairs or actual bill that has been paid.
You destroyed my property.
You were injured during a motor vehicle accident: please provide police report number, details about injury.
N/A
You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
N/A
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: 16 227961
If yes, what law enforcement agency responded?
Saint Paul
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
Walmart on University that I believe is now closed.
What would you like to see happen to resolve this claim to your satisfaction?
Compensation for my property sent in check form to me at 4507 Douglas Dr N., Crystal, MN 55422.
Were there witnesses to this incident? Please provide names and contact phone numbers:
You have all the reports already.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: Make: Model: Color:
N/A
License Plate #: State vehicle is registered in: N/A
Registered owner of vehicle: Driver:
N/A
Area(s) damaged:
N/A
If a City vehicle was involved, License Plate #: _ Color:
N/A
Was there City insignia on the vehicle? Driver’s Name: N/A
Other property damaged: GATLIN'S backpack, a laptop, an unknown electronic device, clothes, hygiene, and $95.
For injury claims of any type.
What part of your body was injured?
N/A
Did you go to the emergency room or urgent care? Where? N/A
Was medical treatment received? Where?
N/A
First day of medical treatment? Are you still receiving medical treatment? N/A
Did you miss any work as result of this incident? N/A
Employer(s): N/A
How much time have you missed from work? _N/A
If you are submitting other documents, please state what you are attaching and how many pages: You have all the documents and reports to affirm what I'm saying.
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: Douglas Lamont Gatlin Jr
Signature of Person submitting this form:
Electronically signed: D.G., Douglas Lamont Gatlin Jr.
Relationship of person signing to Party making the claim: Myself
Date document is being signed: 06/08/2023