Chang, Valavis
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: Valavis Last Name: <Chang
Please Indicate Your Pronouns: He/Him/His
Company or Business Name: Home
Is this claim being made by an Insurance Company? If yes, what is your Claim/File Number?
Is this claim being made by an Attorney? If yes, what is your File Number?
If yes, provide your Insured’s/ Client’s Name:
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Street Address: 141 Wheelock Parkway East
City: Saint Paul State: Minnesota Zip Code: </55117
Daytime/Work Phone: Cell Phone: 651-246-9734
Date of Incident or Date Discovered (Must Complete): 12/10/2025 Time:0555-0600
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: City Snow Plow damaging mail box preventing me from receiving mail.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Have camera watching the snow plow.
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.
x 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?
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: Home, 141 Wheelock Parkway East, st paul, mn , 55117
What would you like to see happen to resolve this claim to your satisfaction? reimbursment
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? Driver’s Name:
Other property damaged: Mailbox
For injury claims of any type.
What part of your body was injured?
Did you go to the emergency room or urgent care? Where?
Was medical treatment received? Where?
First day of medical treatment? Are you still receiving medical treatment?
Did you miss any work as result of this incident?
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:
3 Photos and 1 video attach to email.
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: Valavis Chang
Signature of Person submitting this form:
Relationship of person signing to Party making the claim:
Date document is being signed: 12/16/2025