Diaz, Mario
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: ___________Mario__________ Last Name: ________Diaz_______________________________________
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? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: 617 S Stryker Ave __________________________________________________________________________________________
City: ____________________Saint Paul__________________________ State: ____Minnesota____________________ Zip Code: ___55107________________
Daytime/Work Phone: __612-295-8797________________________________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 7/10/2025 Time: _____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: My Black Suburban was parked out side my house on the street and the city street sweeper hit
my truck with the passenger side of their truck to my back driver side of my truck. There was signs posted on the street of the upcoming cleaning for the day in question on 07/10/2025.
____________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __One of the city of Saint Paul street sweeper caused damage to the back driver side of my truck
that was parked out side my house on the street when they were driving by cleaning the street.__________________________________
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? YES / NO
If yes, please provide the police report case number: no__________________________
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:
617 S Stryker Ave #Saint Paul MN 55107__________________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? I Would like the city of Saint Paul to pay for damages caused to my truck during the street cleaning on
07/10/2025.____________________________________________________________________________________________________________
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 _______________________________Currently
trying to obtain camera footage from my building regarding the accident. The Office number for the building is 651-202-3436____________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2006______ Make: ________chevy_________ Model: ____suburban______________ Color: ___black_______________
License Plate #: _________________________ State vehicle is registered in: Minnesota___________________________
Registered owner of vehicle: Mario Diaz_____________________________ Driver: __________________________________________
Area(s) damaged:___back driver side to truck and bumper.___________________________________________________________________________________
If a City vehicle was involved, License Plate #: _____N/A____________________________ Color: _______________________________
Was there City insignia on the vehicle? YES / NO Driver’s Name</w: ___Still not determined.___________________________________________________
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? ________NO___________________________________________
Was medical treatment received? YES / NO Where? </__N/A______________________________________________________________
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): _________________________________________________________________________________________________
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: Mario Diaz____________________________________________________________ <
Signature of Person submitting this form: Mario Diaz_______________________________________________________
Relationship of person signing to Party making the claim: Myself________________________________________
07/12/2025 Date document is being signed: Mario Diaz
Revised March 2023