Carmichael, NickRevised 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: _____Nick___________________________ Last Name:
Carmichael_______________________________________________
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? 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: _______________________________________________________________________
Street Address: ______488 Holly Avenue
_________________________________________________________________________________________
City: ______Saint Paul ________________________________________ State: ____MN____________________ Zip Code:
___________________
Daytime/Work Phone: __________________________________ Cell Phone: _____651 262
7809________________________________________
Date of Incident or Date Discovered (Must Complete): 11/15/2025 Time: _____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __I have a prepaid slip for 2026 at
watergate marina and the city is saying they will not honor the contract for 2026.__________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____The city did not inform me or any other
clients at the marina that you were canceling the your boat club marina manager for 2026. You also didn't tell me or anyone that
they owed they city money and that is why they are being canceled. I and Everyone at the marina should have been notified that
they were in default when it initially happened or within a reasonable amount of time. The city likewise knows that marina's are in
the business of charging for things like storage and slips in advance i.e in the fall of 2025. I need the city to notify whoever is bidding
on the watergate marina contract for 2026 that they have to honor existing slip agreement because of this. I otherwise need the city
to refund me the amount I paid for the slip for 2026.
You cannot not honor my or anyone's contract with this context, you are absolutely responsible and a stakeholder in this.
________________________________
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.
Revised March 2023
☐ 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:
__________________Watergate
marina__________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
_________________The city simply needs to notify new providers for the marina that because it was aware the previous service
provider was in default and they ware going to seek a new provider and they did not notify the marina customers that they were
cancelling the new provider that the customers they paid for slips that the new provider needs to honor for 2026 OR pay back the
amount I paid to the old service provider for my slip for 2026.
___________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _________ 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: ______________________________________________________
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? ________________________________________________________________
Revised March 2023
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: _____2026 Watergate marina
slip agreement.____________________
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: _____________Nick Carmichael________________________________________________
Signature of Person submitting this form: ___ ____________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed: 11/21/2025