Pederson, Dan
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: Dan_________________ Last Name: Pederson_____________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: N/A___________________________________________________________________________
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: N/A___________________________________________________________________
</
Street Address: 1260 Victoria Street N___________________________________________________________________________
City: Saint Paul State: Minnesota Zip Code: 55117
Daytime/Work Phone: 651-260-8402 Cell Phone: 651-260-8402_
Date of Incident or Date Discovered (Must Complete): work is planned for summer 2025 Time: _____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: As part of the Wheelock Grotto reconstruction phase 1 project, infiltration work is planned for
the area of Orange Avenue between our lot and the street. The planned work will be very close to a large silver maple tree on our lot; the work will cut the tree’s roots within the tree’s
dripline. There is limited area of pervious ground currently within the tree’s dripline and planned work will either remove or kill much of the tree’s already limited root system. Without
roots needed for the tree’s structure and water intake, the tree will either die or it will be blown over in a wind event in a matter of years. This is problematic for a few reasons:
This will result in the loss of a tree which benefits the neighborhood. When the tree dies or blows over, removal of the tree will be very expensive for me. If the tree blows over there
is also the likelihood of considerable damage to the detached garage and house on my lot. During a storm in August 2024, our neighborhood had examples of windblown tree damage to property
which resulted from the prior compromising of mature tree root systems. A homeowner paid tens of thousands of dollars to have a windblown tree removed from their lot, a retaining wall
was destroyed, their detached garage was damaged and their car was totaled when the tree landed on it. As in my case, the root damage which caused the tree to blow over did not occur
within their lot so was out of their control. If the City of St. Paul proceeds with work as planned, they do so with the understanding that damage to my property will almost certainly
result.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
St. Paul is making an operational level decision with an almost certain outcome of damage to 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.
☐ 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:
_______________________________________1260 Victoria St. N_____________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? The City of St. Paul should agree to pay costs associated with future damages caused by the planned infiltration
system.
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 ___N/A______________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _N/A______ 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? _N/A_________________________________________________________________________
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: _________________________
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: Dan Pederson <
Signature of Person submitting this form: DanPederson____________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed: 3/23/2025
Revised March 2023