Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Claim by Jane Spurling
Claim Form http://www.cityofdubuque.org/printer_friendly.cfm?pageid=155 f' CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ~r This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form iris full and attach any additional information that supports your claim. The claim must be filed with the City Clerk at City Hall, 50 West 13th St., Dubuque, IA 52001. It will then be referred to the appropriate department for investigation and to the City Attorney's Office. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation. The final decision on all claims is made by the City Council. No employee of the City of Dubuque has the authority to make any representation to you as to whether your claim will or will not be paid. 1. Name of Claimant: 2. Address: 3. Telephone Number: <<] (o ~ • Fi ~S ~ - ~1R ~ 4. Date of Incident: ~UUt.I ~~" 7.7~' 5. Time of Incident: 6. Location of Incident (Be specific): l{• i S hn r r~ +o bP ~p~ C iti t` P,~(,('i~~-~°{~.f'. whe.r-e l P~r,~~n-~v.~~ +he w>a~~ r~'-tn~ U 7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.) A - 7" w , ,t ~ra Y~ s~ 1 ~i , /~c.i c-~ C ~ Li r0 u ~ ~ yU vt r,_,a.._ ~P~n,~sala~,~ u a,? ~, I ha n ~ r ~ S ~'rech 1/ cam, n ~e~ 1/~//vcu ~.~-~L' ~1r.~Sr 7herN Wire not nnJ ~i'4n~~ rndico~iiia ~rPSh painf. 8. What were weather conditions like? ~Qr'~'!'1/~ / 9. Give name and address of any witnesses: /VC~nP 10. Did police investigate? (If so, give names of officers.) 11. Was anyone injured? (If so, give names, addresses, and extent of injuries.) 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) r 2©0~1 ~5~i~,url~-n hard brjgh+ ~~I~/JaiYl~ ~plr~ reC1 n I t~ ~ , -1-h ~ rj ~rN r.< c;rl G ~, ~- tr a ~ ir,~-,~_~ ~i~}~ _~-r~~~e.4~1n.~ca III remctt~~l . 13. What other damages do you claim, if any? /~D l1/~ 1 of 2 9/23/2008 7:30 AM -~--~- ~~ o o ~ ® ~l~?Ja?J ~®Ll CylXy~ ~~~lStl~~ ~~ O O Truck &-.Car Accessories 3125 Cedac Crest Ridge>#~Z ~ Dubuque, Iowa 52003 0 `' 59~-7457 (563) 6900 ' 7 -. u, ~ r ,~ . ' Date: - ~ " ~' ~ r - \ , ~ ~ ' r ~ ~.. ~ --• -INVOICE .; ~ ~~ o _ Year M e Stock Job--~escri tion u, w r ~. r J ,.. . „T ~~' f:. Y j; Subtotal' ~ = ~ ~~ `~ Tax ,: ~ ~ '; Total ~~ } 4a, It ,~ ,,~a1 o-+~ ~_~ m 0 m ~ °> n v 70 ~~ ~ ~ n ~No~ n ~ N RI o~C~1~77 N ~ W r- n z ~z -~ m m Q ,~..~:..~:•. 0 ~ r [~~ a~ ~ ~~~ ~ ~ ~;, 0 .p