Moore, MariamaNOTICE 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 answer to each question. If more space is needed, attach additional sheets. Please note that you will not
be contacted by telephone to clarify answers, so provide as
much information as necessary to explain your claim, and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process
can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed, and both pages completed. If something does not apply, write ‘N/A’.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name Mariama Middle Initial ____ Last Moore
Company or Business Name ___________________________________________________________________
Are You an Insurance Company? Yes / NoX If Yes, Claim Number? _______________________
City Saint Paul State Minnesota Zip Code 55102
Daytime Phone (____)____-______ Cell Phone (612) 319-8880 Evening Telephone (____)____-______
Date of Accident/ Injury or Date Discovered _______________________ Time _________ am / pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or
responsible for your damages.
My claim is against Saint Paul Police Officers, Last Name Kempe and Martell. My claim is for Minn Stat 466.02 Minnesota Municipal Tort Liability Act for Negligence. For failing to act
and protect I spoke with both officers relating to my non emergency calls for reported ongoing psychological stalking, stalking, sexual harassment and a pattern of bias and discrimination
from a tenant on tenant situation.
The reports were made in March and April and before December and it still is ongoing I spoke with Saint Paul Police Officer Martell about the ongoing stalking and sexual harassment
and harassment and the hostile living environment he told me over the non emergency dispatch call back number assigned to him that he would look up this person information in the police
system to see who she/or he was
Living in the apartment and that they were going to contact the property manager to get the name or they would they would also send an officer out to knock on the person door. And that
he would get the name from the property manager and look up who she/or he was and provide the name to me so I could file for a Harassment Restraining Order.
I never heard back from the police officer last name Martell but I got another call from Saint Paul Police Officer Last name Kempe he asked me about this person that been psychological
stalking, stalking and sexual harassing me and how it been ongoing he asked me if I had any evidence about it and I said yeah have other police reports about the ongoing harassment
but no text, call or emails just reports and that I got proof from my doctor and therapist about how I have a stalker etc …
He asked me if I had evidence and that he needed evidence so he could give the information to the judge to be able to pursue and press charges on this person but he needed proof but
he also told me that he would get this he/or she name that been doing the ongoing harassment
And that he would provided it to me so I can file for a harassment restraining order I never heard anything back from both officers Kempe or Martell with this individual name and they
never sent an officer out to knock on his door or nothing and I don’t even know if they contact the property manager but the ignored everything and did nothing they said they would
do to give me the stalkers name
I didn’t hear anything back from Saint Paul Police Department or their Police Officers That I spoke with and their negligence has caused me to experience personal injuries from the ongoing
harassment and the stalker attacking me psychologically from the emotional abuse and mental assault worsen, me experiencing more panic attacks, my anxiety worsening, and my breathing
and me experiencing ongoing fear and being in fear of my life threatened and frightened.
They failed to act and protect or do anything they said they were going to do and ignored the seriousness of this stalking and their behavior and how I have to keep booking and going
to therapy and making more and more non emergency police reports of this ongoing stalking and sexual harassment and harassment and how they don’t press criminal charges against this
person that been stalking me ongoing for 6 months.
How I been faced with personal injury of psychologically trauma, mental assault and emotional abuse loss of enjoyment of life fear, unsafe, emotional distress and keep going seeking
therapy from the stalking and the ability not to enjoy my daily activities from them not intervening and not stopping the ongoing harassment, and stalking.
These police officer breach their duty, duty of care, causation that cause proximate of my ongoing personal injury from psychical harm and trauma from this stalker and harasser.
For this claim I am demanding the total cap amount of $500,000 if this is ignored and followed up on or deny I will pursue suing in District Court under Minn 466. 02 for the violation
from both police officers
And I will be demanding $500,000 for punitive damages as well if I cannot get it for the personal injury because there is no documentation the police officers have the police report
with them they never proved any documentation with the stalker names on it or a citation or anything for evidence I only have my non emergency reports that they took
Please check the box(es) that most closely represent the reason for completing this form: N/A
My vehicle was damaged in an accident My vehicle was damaged during a tow
My vehicle was damaged by a pothole or condition of the street My vehicle was damaged by a plow
My vehicle was wrongfully towed and/or ticketed I was injured on City property
Other type of property damage – please specify N/A ______________________________________________
Other type of injury – please specify. N/A _______________________________________________________
In order to process your claim you need to include copies of all applicable documents.
For the claims types listed below, please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property
of the City. You are encouraged to keep a copy for yourself before submitting your claim form.
Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs; detailed list of damaged items
Injury claims: medical bills, receipts
Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2 – Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims – please complete this section
Were there witnesses to the incident? Yes No X Unknown (circle)
Provide their names, addresses and telephone numbers: ________________________________________________
_____________________________________________________________________________________________
Were the police or law enforcement called? Yes X No Unknown (circle)
If yes, what department or agency? Saint Paul Police Department Case # or report # 26811649 etc al… there are other reports but I have two with Kempe and Martell but I think this is
the case number
Where did the accident or injury take place? Provide street address, cross street, intersection, name of park or facility, closest landmark, etc. Please be as detailed as possible.
If necessary, attach a diagram.
160 Western Ave S Apt 218 Saint Paul MN 55102
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your
The cap $500,000 by law for the violation of Minn 466.02
Or $500,000 in Punitive Damages for the violation of Minn 466.02
Vehicle Claims – please complete this section ________ check box if this section does not apply
Your Vehicle: Year __________ Make _______________ Model_________________________________
License Plate Number _______________ State _____ Color ________________________ Registered Owner __________________________________________________________
Driver of Vehicle ___________________________________________________________
Area Damaged______________________________________________________________
City Vehicle: Year __________ Make _______________ Model_________________________________
License Plate Number _______________ State _____ Color ________________________ Driver of Vehicle (City Employee’s Name)_______________________________________
Area Damaged______________________________________________________________
Injury Claims – please complete this section ________ check box if this section does not apply How were you injured?
Psychologically, Emotional Abused, Physical Harm and Truama from the no intervention from the police officer and being attacked by the stalker mental assault
What part(s) of body were injuries? My mind and from tension heads migraines etc.. from the psychological mental assault
_______________________________________________________________________________________________
Have you sought medical treatment? Yes X No Planning to Seek Treatment (circle)
When did you receive treatment? Therapy and Ongoing Therapy Doctors Session provide date(s)) Name of Medical Provider(s): Dr. Okubo ______________________________________
Address Bandana Square Telephone ______________________
Did you miss work as a result of your injury? Yes No X
When did you miss work? X ____________________________________________________________(provide date(s)) Name of your Employer:
___________________________________________________________________________ Address__________________________________________________________Telephone______________________
Check here if you are attaching more pages to this claim form. Number of additional pages ____.
By signing this form, you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed April 24th 2026
Print the Name of the Person who Completed this Form: Mariama Moore
Signature of Person Making the Claim
Mariama Moore
Revised February 2011