Harris, MarsheanaNOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota
Minnesota State Statute466.05 states that “…every person…whoclaims damages from any municipality…shallcause to be presented tothe governing body of the
municipalitywithin180days after the allegedlossor injury is discovered a notice stating thetime,place,and circumstancesthereof,and the amount ofcompensation
orother relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question.If you have additionaldocumentation,you may addthose
documentsto your submission.You will not be contacted bytelephone unless clarification is needed.Theclaim process for investigations can take upwardsof
four (4)weeks.This form must be signed,dated withall applicable sections completed.Submission this completed form tothe Saint Paul CityClerk’s Officeby
email(cityclerk@ci.stpaul.mn.us),fax(651-266-8574)ormail addressedto “Saint Paul City Clerk,15 West Kellogg Blvd.,Suite 310,Saint Paul,MN 55102”.
Claimant:First Name:___Marsheana_____________________________Last Name:
___________________________Harris____________________
Please Indicate Your Pronouns:X ☐She/Her/Hers,☐He/Him/His,☐They/Them/Theirs
Company or Business Name:
___________N/A_________________________________________________________________________
Is this claim being made by an Insurance Company?YES /NO If yes,what is your Claim/File Number?
_____________NO____________
Is this claim being made by an Attorney?YES /NO If yes,what is your File Number?
__________________NO_____________________
If yes,then provide your Insured’s/Client’s Name
_______________________N/A____________________________________________
Street Address:__________________470 Western Ave N Apt
122_____________________________________________________________________________
City:______________Saint Paul________________________________State ________________Minnesota_________Zip Code
_____55103______________
Daytime/Work Phone __________________________________Cell Phone
___________________9528560629___________________________
E-mail ______________________Harrismarsheana@gmail.com___________________________
Date of Incident or Date Discovered (Must complete)____________7/14/23___________________Time
_______________7:25am______________
Please state,in detail,what happened that prompted you to file a Notice of Claim Form.______My vehicle was damaged on its
right side ,by the city of Saint Paul's BLVD tree,my windshield is completely shattered,i have damage to my right interior vent ,there
is a dent across the front right and back right of my vehicle._____________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages?____________Because the city of Saint
Paul's property damaged 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.
RevisedMarch 2023
☐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.
This section must be completed for all claims.
Is there a police report for this incident?YES /NO NO there was not a claim filed because the police told me that they could not
help me and that i needed to call my insurance company when i called to report the tree and asked them to come and remove it.
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.
______________________________________Western and
Aurora______________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
_________________________I would like to see the Damages to my car repaired with no out of pocket
cost.______________________________________________________________________________
Were there witnesses to this incident?Please provide names and contact phone numbers:
__________________Yes after the police denied me assistance i called the fire department Station 18 and they came and saw the
tree on top of my car removed the trees and pulled my vehicle from under the damage for me because of all of the glass
everywhere._______________________________________________________________________________________
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year _____2011____Make _____ford____________Model ____fusion______________Color
________white____________
License Plate #________JGD002_________________State vehicle is registered in _______MN____________________
Registered owner of vehicle _________Marsheana Harris_____________________Driver
__________________________________________
Area(s)damaged _______Windshield,front hood,back right side of trunk right side dented ,and vent inside damaged as
well_______________________________________________________________________________
If a City vehicle was involved:License Plate #_________________N/A________________Color
_______N/A__________________________
Was there City insignia on the vehicle?YES /NO Driver’s Name
_________________________NO_____________________________
Other property damaged:
______________NO_________________________________________________________________________
For injury claims of any type.
RevisedMarch 2023
What part of your body was injured?
_____________________NONE________________________________________________________
Did you go to the emergency room or urgent care?YES /NO Where?
________________N/A___________________________________
Was medical treatment received?YES /NO Where?
______________________NO__________________________________________
First day of medical treatment?_______N/A______Are you still receiving medical treatment?YES /NO
Did you miss any work as result of this incident?YES /NO
Employer(s)________________________Yes,My Employer Is Allina Health Customer Experience Center,Coon
Rapids_________________________________________________________________________
How much time have you missed from work?_______________6 days of unpaid 8 hour missed days because of the accident
____________________________________________________
If you are submitting other documents,please state what you are attaching and how many pages.________I will be submitting 6
pages of photos showing that the tree fell on my vehicle _________________
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:___________Marsheana Harris__________________________________________________
Signature of Person submitting this form:_________Marsheana Harris______________________________________________
Relationship of person signing to Party making the claim:_____SELF_____________________________________
Date document is being signed _______________7/14/23_______________
RevisedMarch 2023