Kidau, Nohn (2)
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, and 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 _Nohn_ Last Name < Kidau
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? </w:t></w:r></w:s If yes, what is your Claim/File Number? <_____________________
Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
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Street Address: _________________________________________________________________________________________
City: ____________________________________________ State ___________________ Zip Code <__________________
Daytime/Work Phone _______________________________ Cell Phone ____________________________________________
Date of Incident or Date Discovered (Must complete) 11/3/2022Time 4:22pm _________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was on my way home from Saint Mary’s University of Minnesota, Twin Cities Campus. I took Bus
number five on Chicago Ave. to Downtown Minneapolis, were I boarded the Green Line train going to St. Paul. I got off at the Westgate state, walked across the University Avenue to the
intersection of Berry Street.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The city of Saint Paul construction workers are dangerously careless. They
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.
I was on my way home from Saint Mary’s University of Minnesota, Twin Cities Campus. I took Bus number five on Chicago Ave. toward Downtown Minneapolis. At the U.S. Bank Stadium station,
I boarded a Green Line Train going toward St. Paul. I got off the train at the Westgate Station and walked across University Avenue to the intersection of Berry Street. The traffic light
across Berry Street was green, so I decided to walk across Berry since I live on that side of Berry. At that time there were no construction signs in that area. It seems they were all
done with their work in that area. As I walked across Berry Street, I stepped on the end of a metal plate, and the opposite end lifted with such force that, interrupted my walk, and
threw me over a metal plate that covered drainage. They never sealed down the mantle plate which cost the fall.
I broke a bone in my elbow and sustained a serious injury to my carol tunnel, which is causing me to have sleepless nights. The Orthopedic has scheduled an EMG on my left wrist to determine
whether I will need surgery. Meanwhile, I continue to feel burning pain that feels like my left parm is on fire.
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 ___N/A_________________
Revised December 2021
If yes, what law enforcement agency responded? ______N/A_____________________________
Where did the incident take place? Please provide a street address, intersection or name of City Park or facility.
The incident took place at the intersection of University Ave and Berry Street on the south of side of University Ave as I was walking across Berry Street.
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? Since I do not know the long-term effect of my injury, I would like the City of Saint Paul to pay the amount
of $50,000 (fifty thousand dollars). If these injuries do not lead to surgery, we can negotiate.
Were there witnesses to this incident? There were a couple of people who witnessed the incident and lifted me up from the ground, but they, quickly left before I came to myself because
their bus was leaving. Please provide names and contact phone numbers. Since they left quickly, I was unable to get their names, but the fall took place right in front of one of your
63 buses. There were people on the sport who lifted me off the ground they left in a rush because their bus was leaving. I was in a state of confusion at the time.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year __N/A____ Make _____N/A____________ Model ___N/A_________________ Color ______N/A__________
License Plate # _____________________ State vehicle is registered in _____N/A___________________
Registered owner of vehicle ________N/A______________________ Driver _______N/A_______________________________
Area(s) damaged _______________N/A_________________________________________________________
If a City vehicle was involved: License Plate # ______________N/A_________________ Color ____________N/A___________
Was there City insignia on the vehicle? N/A Driver’s Name </w_________N/A_____________
Other property damaged: _______________N/A______________________________________
For injury claims of any type.
What part of your body was injured? I broke a bone in my right elbow, and seriously hurt my left wrist, from which, I am having numbness and tingling, I am being treated by an occupational
therapist at Hennepin County for both injuries. Because of the tingling and numbness, I am unable to sleep on my left side. This forces me to sleep on my right where there is also a
broken elbow. Therefore, I am having sleepless nights either way. According to the orthopedic and the occupational therapist, my elbow may not fully recover to its original state. For
the wrist, an EMG is scheduled for early May 2023 to determine what is causing the pain. Another part of my body injured was my left knee, but it is healing better than the rest.
Did you go to the emergency room or urgent care? Yes, Where? I went to Hennepin County Medical Hospital Emergency room, and the x-ray showed a broken bone in my elbow.
Was medical treatment received? Yes, and I was referred to Orthopedic and ordered an Occupational Therapist. She is currently treating me at the Hennepin County Medical Center Specialty
Center- 715 South 8th St. Minneapolis, MN Where? </______________________________________________________________
First day of medical treatment? November 42023 Are you still receiving medical treatment? Yes
Did you miss any work as a result of this incident? N/A Employer(s) <_______________________________________________
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. ___N/A
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: _Nohn Rebecca Kidau_ <
Signature of Person submitting this form: Nohn Rebecca Kidau
Relationship of person signing to Party making the claim: __Self_
Date document is being signed and summited on 5/2/2023
Update
The EMG result showed a lot of damaged nerves in the injured area. The neurologist at Hennepin County Hospital recommended surgery on my left wrist and referred me to orthopedics. The
Orthopedic recommended trying a steroid injection to see if that could relieve me of pain. So, they gave me a steroid injection. My hand was numb for about two weeks. After the numbness
stopped, I started to the numbness and tingling pain came back. On the early morning of August 9, 2023, the surgery took place at the Hennepin County Medical Center in the Orthopedics.
The healing process is slowly ongoing with pain. The medication I am taking makes me drowsy. That is where things stand at this point. As was predicted, after over eight months of occupational
therapy, my elbow still hurts when folding and unfolding and is even painful when I touch the nerves around the area where the bone was broken during the fall.
Nohn Rebecca Kidau