Weiss_Fillable Notice of Claim formNOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
MiŶŶesota “tate “tatute ϰϲϲ.0ϱ states that ͞…eǀery persoŶ…ǁho Đlaiŵs daŵages froŵ aŶy ŵuŶiĐipality…shall Đause to ďe preseŶted 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 compensat ion
or other relief deŵaŶded.͟
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 is to the Saint Paul City Clerk’s Office. You may email, fax
(651-266-8574) or ŵail the forŵ. MailiŶg address is ͞“aiŶt Paul City Clerk, ϭ5 West Kellogg Blvd., “uite ϯϭϬ, “aiŶt Paul, MN 55ϭϬϮ͟
Individuals: First Name __Michelle_________________________ Last Name __Weiss_______________________________________
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? If yes, what is your Claim/File Number?: _____________________
Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________________
If yes, theŶ proǀide your IŶsured’s/ ClieŶt’s Name ____________________________________________________________
Street Address: ____265 Dayton Ave. Apt. F_____________________________________________________________________
City: ______________St. Paul______________________________ State _______MN____________ Zip Code ______55102_______
Daytime/Work Phone _______________________________ Cell Phone ____________612-295-2350_________________________
Date of Incident or Date Discovered (Must complete) 1/6/2022Time ___12:06AM______________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _My car was towed from a section of
street that had been plowed to the curb. I intentionally chose this space to park, because the section had been plowed through to a
no parking sign. Beyond that, there were many other cars parked further along the same road that were not towed, despite parking
in sections that had not been cleared to the curb. Additionally, there was no new snow accumulation on my car, because the snow
had stopped when I parked there. _
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _I believe this was a wrongful tow and I
have communicated with a hearing officer who said they would waive the ticket fee. _________________
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 pai d.
☐ 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.
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______________
Revised December 2021
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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.
_________Dayton Avenue, between Western and Virginia_____________________________________________________________
Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your satisfaction? __I would like to be refunded for the price I paid when
picking up my car at the tow lot. That total was $335.08.___________
Were there witnesses to this incident? Please provide names and contact phone numbers. ____No__________________________
For property damage claims, including vehicle accidents.
Your ǀehicle’s iŶforŵatioŶ: Year ___2009___ Make __Toyota_______________ Model ___Corolla_________________ Color
___Red_____________
License Plate # ____BBY231_________________ State vehicle is registered in _____MN___________________
Registered owner of vehicle ____Michelle Weiss_______________ Driver _____Michelle Weiss_______________
Area(s) damaged ___________________________________________________________________________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driǀer’s Naŵe _____________________________________________
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, including my car
at lot ǁith Ŷo Ŷeǁ sŶoǁ accuŵulatioŶ coŵpared to others oŶ the lot, photo of soŵeoŶe’s car oŶ DaytoŶ Aǀe shoǁiŶg that the
whole street was not plowed, photos of the section of street where I parked and it had already been plowed to the
curb.___________________
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: ___________Michelle Wiess_____________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: ___Self________________
Date document is being signed 1/28/2022
Revised December 2021
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