Black, Clayton (8.7)
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: _Clayton________________ Last Name: ___________Black_____________
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 If< yes, what is your Claim/File Number? ____250612558__________
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: _______________________________________________________________________
</
Street Address: ___1056 Portland Ave__________________________________________________________________
City: _________Saint Paul____________________ State: ___MN_____________ Zip Code: ____55104_______________
Daytime/Work Phone: __________________________________ Cell Phone: ______651-206-5972____________________
Date of Incident or Date Discovered (Must Complete):07/27/2025_________________________Time: ___8:00pm__________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___A storm came through and caused a tree limb to fall on my insured’s 2015 Dodge Grand Caravan.__________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___The tree did not seem well maintained as it was rotted on the inside._________________________________
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:
_______1056 Portland Avenue Saint Paul MN 55104_________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? ____I would like the payment reimbursed for the claim and my insured’s $1,000 deductible.____________________________
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent><w:sdtEndPr><w:rPr><w:rFonts w:cs="Calibri" w ____ Melissa Moore:
(651) 272-9494 and Jeannine Emery: (206) 963-4228________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2015____ Make: __Dodge___ Model: __Grand Caravan__ Color: __grey_____________
License Plate #: ________NVP377_________________ State vehicle is registered in: ___MN________________________
Registered owner of vehicle: _____Clayton Black_______________ Driver: __________N/A_____________________
Area(s) damaged:___Windshield, roof, front door, pillars_______________________________________________
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? _____________________________________________________________________________
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: _____Photos from the date of loss, 2 estimates._16 attachments including this form___________________
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: ______________Horace Glass III_________________________________________ <
Signature of Person submitting this form: ___________Horace Glass III____________________________________________
Relationship of person signing to Party making the claim: ______Auto insurance Adjuster________________________________
Date document is being signed:08/07/2025 _____________________
Revised March 2023