Powell, ZoeNOTICE 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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon
or other relief demanded.”
Please complete this form in its en1rety by clearly typing or prin1ng your answers to each ques1on. If you have addi1onal documenta1on, you may add those
documents to your submission. You will not be contacted by telephone unless clarifica1on is needed. The claim process for inves1ga1ons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sec1ons 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: _Zoë___________________________ Last Name: __Powell_________________________________________
Please Indicate Your Pronouns: ⿎ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: __N/A_______________________________________________________________________________
Is this claim being made by an Insurance Company? YES / NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an AKorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: __876 West 7th Street Apt. 343_____________________________________________________________________
City: __Saint Paul____________________________________ State: ___MN__________________ Zip Code: __55102____________
Day[me/Work Phone: _(804) 551-1486_____________________ Cell Phone: __(804) 551-1486______________________________
Date of Incident or Date Discovered (Must Complete): __3/13/2023__________________ Time: __3:45 pm_____________________
Please state, in detail, what happened that prompted you to file a No[ce of Claim Form:
During the city-wide 1-sided parking ban in March, my car was towed. I just had a mee[ng with a hearing officer who dismissed my
cita[on (#629600128190) because the spot where I was parked was not clearly the “even” side of the street. I am making this claim
today to be refunded for the $290.08 I had to pay the impound lot to retrieve my vehicle.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
The city towed my car when it should not have.
Please check the reason that most closely describes the reason for your submiBng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiKed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two es[mates for repairs or actual bill that has been paid.
☐ Automobile damage from a street defect or pothole: please provide two es[mates for repairs or actual bill that has been paid.
⿎ Automobile was towed and may or may not have sustained damage: please provide copy of towing [cket (if available), receipt
from Impound Lot, and two es[mates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing [cket (if available), receipt from Impound Lot, and two es[mates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two es[mates for repairs or actual bill that has been paid.
Revised March 2023
☐ 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.
ConEnue to page 2 of NoEce of Claim Form. Failure to complete and return both pages will result in delays.
This secEon 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: ___________________________
If yes, what law enforcement agency responded? ____________________________________________________________
Where did the incident take place? Please provide a street address, intersec[on or name of city park or facility:
Palace Avenue between Duke and Erie street (on the side of the street next to the warehouse building)
What would you like to see happen to resolve this claim to your sa[sfac[on?
I would like to be reimbursed $290.08 for the towing fees I paid in order to retrieve my vehicle.
Were there witnesses to this incident? Please provide names and contact phone numbers:
I at work at the [me of the tow and did not witness the event.
For property damage claims, including vehicle accidents.
Your vehicle’s informa[on: Year: 2009_____ Make: Nissan___________ Model: Versa_____________ Color: White_____________
License Plate #: CUX-380__________________ State vehicle is registered in: MN___________________________
Registered owner of vehicle: Zoë Powell___________________ Driver: Zoë Powell_________________________________
Area(s) damaged: N/A__________________________________________________________________________________
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. N/A
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 s[ll receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
How much [me have you missed from work? _____________________________________________________________________
If you are submiBng other documents, please state what you are aKaching and how many pages: 3 pages total: Copy of cita[on (1
page), Copy of Towing Receipt/Payment Receipt (1 page), Screenshot of Google Maps of where the incident occurred- a grey pin
indicates where the vehicle was parked (which is an odd address) (1 page)
Revised March 2023
By signing this form, you agree that all informaEon provided is true and correct to the best of your knowledge.
Please NOTE that submiBng a false or misleading claim can and will result in prosecuEon under Minnesota Statutes.
Name of Person comple[ng form: Zoë Powell_____________________________________________________________
Signature of Person subminng this form: _______________________________________________________
Rela[onship of person signing to Party making the claim: Self__________________________________________
Date document is being signed: 5/16/2023_____________________
Revised March 2023