Dhayow, Mohamoud
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: Mohamoud Last Name: Dhayow
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ____________________________________________________________________________________
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: 843 Magnolia Ave E
City: Saint Paul State: MN Zip Code: 55106
Daytime/Work Phone: 651-757-0309 Cell Phone: 651-757-0309_
Date of Incident or Date Discovered (Must Complete): 7/22/2023 Time: 4:00 PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I am writing to formally submit a claim for damages to my vehicle as a result of a storm that
occurred on July 22, 2023, at approximately 4:00 PM. The storm caused a tree branch to fall onto my automobile, resulting in significant physical damage. During the aforementioned storm,
a tree branch broke off and fell directly onto my parked vehicle, causing substantial damage to the roof, windshield, and hood of the vehicle. The impact also led to additional internal
damage, affecting the vehicle's functionality and safety. I have attached photographs of the damage to this claim for your reference. As a responsible vehicle owner, I promptly took
the necessary steps to address the situation, including notifying my insurance company and obtaining a repair estimate from a reputable auto body shop. I kindly request that the city
consider my claim for reimbursement of the repair expenses incurred due to this incident. I believe that the circumstances surrounding the fallen tree branch were beyond my control and
were directly caused by the severe storm on July 22, 2023.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I would like to bring to your attention the following points that support the city's potential
responsibility for the damages:1. City-Owned Trees: The tree from which the branch fell is located on public property and is therefore owned and maintained by the City of Saint Paul.
As such, the city has a duty to regularly inspect and maintain its trees to prevent hazardous conditions that could lead to such incidents.2. Foreseeability and Negligence: The storm
on July 22, 2023, was forecasted to be severe, and it was reasonably foreseeable that the high winds and heavy rainfall could lead to tree branches falling. The city has failed in its
duty to take preventive measures, such as pruning or removing weak branches, to mitigate the risk of damage to vehicles and property during such weather events.3. Public Safety and Liability:
The fallen tree branch posed a significant risk to public safety, and the city has a responsibility to uphold the safety of its residents. Neglecting proper tree maintenance and failing
to promptly address hazardous conditions may constitute negligence on the part of the city, potentially making it liable for resulting damages.
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:
843 Magnolia Ave E Saint Paul, MN 55106
What would you like to see happen to resolve this claim to your satisfaction? In light of these considerations, I am requesting that the City of Saint Paul review my claim for reimbursement
of the repair expenses incurred due to this incident.
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 Neighbors have witnessed
the incident and its damage to my vehicle.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2015 Make: Toyota Model: RAV4 LI Color: BLACK
License Plate #: HHU 207 State vehicle is registered in: MINNESOTA
Registered owner of vehicle: Shamsa Dhayow/ Mohamoud Dhayow Driver: N/A
Area(s) damaged: Exterior
If a City vehicle was involved, License Plate #: N/A 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? _____________________________________________________________________________
Did you go to the emergency room or urgent care? YES / NO Where? ___________________________________________________
Was medical treatment received? YES / 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: 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: Mohamoud Dhayow <
Signature of Person submitting this form: s/ Mohamoud Dhayow
Relationship of person signing to Party making the claim: Self
Date document is being signed: 8/9/2023
Revised March 2023