Hanson, ToddRevised March 2023
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 Saint 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: __Todd Hanson___________________ Last Name: __Hanson__________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ____Birch Real Estate LLC_____________________________________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? ___N/A_________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? ___N/A_____________________________
If yes, provide your Insured’s/ Client’s Name: ____N/A____________________________________________________________
Street Address: _____2940 Regent Ave N__________________________________________________________
City: ____Golden Valley___________________ State: __MN______________ Zip Code: __55422__
Daytime/Work Phone: ___651-470-7345___________ Cell Phone: ___651-470-7345____________________
Date of Incident or Date Discovered (Must Complete): 1/28/2025 Time: ___roughly 1 PM__
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __The Saint Paul police department issued a
search warrant against this property to search the upper unit of this property for a person of interest. The warrant was executed and caused one door to be thoroughly damaged as a forced entry was required to exercise the search warrant. __
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _The damage occurred when Saint Paul
policy were executing a search warrant against this 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.
Revised March 2023
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: _Unsure________________
If yes, what law enforcement agency responded? ___Saint Paul Police________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
_____Residential Duplex, 632 Blair Ave in Saint Paul MN 55104__________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
______The work has been completed and I’m looking to be reimbursed. _______________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
___This was initiated by the police. My two contacts at the Saint Paul police department were Officer Aaron Bohlen and Sergeant
Jennifer O’Donnell____
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 #: _____N/A________________ State vehicle is registered in: ___N/A________________
Registered owner of vehicle: ___N/A_____________________ Driver: _____N/A______________________________
Area(s) damaged: The backdoor of 632 Blair was forcefully opened and needed to be replaced. The work has been
completed. _____
If a City vehicle was involved, License Plate #: __N/A_____________________ Color: __N/A______________________
Was there City insignia on the vehicle? NO Driver’s Name: ____N/A___________________________________________ Other property damaged: _The only damage to the property was the backdoor which required structural work to fix/repair/replace
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? NO Where? ___________________________________________________
Was medical treatment received? NO Where? ________________________________________________________________
First day of medical treatment? ___N/A______ Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? NO
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: _The attached estimate is
actually the invoice as the work has been completed. Originally I thought I had more time but due to other security concerns that
came up at the residence I needed this work to be quickly completed once I had more details of the condition of the property.
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: ___Todd Hanson________________________________
Revised March 2023
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed: 3/22/2025