Nyumah, MosesNOTICE OF CLAIM FORM to the Cityof 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: ___Moses______________________ Last Name: __Nyumah____________________________
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? 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, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: _______________________________________________________________________________________________
City: ______________________________________________ State: ________________________ Zip Code: ___________________
Daytime/Work Phone: __________________________________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 2/8/2025 Time: _____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __While parked in the City of St Paul, My
Honda H-RV was hit by a police Squad car and caused damage to the rear driver side.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___Because St Paul Police was involved in
the hit and officer Samuel Betterley gave me the case number to pursue the case.
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 / NO
If yes, please provide the police report case number: ____25021727_______________
If yes, what law enforcement agency responded? _Saint Paul Police Department _
Where did the incident take place? Please provide a street address, intersection or name of city park or facility: ________East 5th
Street, St. Paul, MN________________________
What would you like to see happen to resolve this claim to your satisfaction?
I would like my car to be repair/fix
____________________________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
_________I do not believe so________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ____2019_____ Make: ______Honda_______ Model: ____H-RV__ Color: _____Gray____
License Plate #: _____194 NJ___________ State vehicle is registered in: ______MN_____________________
Registered owner of vehicle: _______Moses Nyumah________ Driver: _____Moses Nyumah____________________
Area(s) damaged: ___Rear corner and side of the driver side and side panel___
If a City vehicle was involved, License Plate #: __I do not have that information____ Color: _ _I do not have that information
_____________________
Was there City insignia on the vehicle? YES / NO Driver’s Name: I do not have that
information__________________________________________
Other property damaged:
______________________No_________________________________________________________________
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?
_______________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):
________________________________________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: _________________________
Revised March 2023
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: ____Moses Nyumah_________________________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: _______N/A___________________________________
Date document is being signed: 3/24/2025
Revised March 2023