Claim Beth LenstraCLAIM AGAINST THE CITY OF DUBUQUE
This written report constitutes your claim against the City of
Dubuque, Iowa. You should complete this form in 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 Street, Dubuque, Iowa 52001-4864. It will then be
referred by the City Council to the appropriate Department for
investigation. Once that investigation is completed, a report and
re=ommendation 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 CLAIMWILL OR WILL NOT BE
PAID.
1. Name of Claimant:
2. Address:
3. Telephone ~,~her:
4. Date of Incident:
5. Time of Incident:
6. Location of incident.
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INOuKY OR DAMAGE.
(Give full details upon which you base your clalm. If a City
employee was involved, give the employee's name.)
8. ~at were weather cOnditfons llk~?
9- Give n~e aha aadress of any witnesses.
10. Did police investigate? (If so, give names of officers.)
11.
Was anyone injured?
inj uriee. )
(If s~?~>~i~ddress ~nd extent of
12. Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of d~mages br
describe basis for ascertaining extent of damage.)
13.
14.
15.
W~at other damages do you claim, if any?
Have you been compensated for any part or all of your claim by
any insurance company? (If so, give name and address of
What amount do you claim from the City of Dubuque?
16. Why dO~ you claim the City of Dubuque is responsible?
Have you made any claim against anyone else for daunages as a
result of this incident?
18. If the answer to Question 17 is yes, have you received an~
payment frock_that source, and if so, in what amount?
Dated at Dubuque, Iowa,
2001.
(Revised January, 2000)
this
(Prtn~ Name) '