Claim by Zachary Thomas Hallman Copyrighted
March 4, 2019
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUM MARY: Hope Ehlinger for vehicle damage,Audrey Gottschalk for
vehicle damage, Zachary Hallman for vehicle damage,
Andres Liza for property damage, Kalyn Nowacki for
vehicle damage, Conor Shoellhorn for vehicle damage,
Nicole and Ricardo Woods for personal injury/vehicle
damage,
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City
Attorney
ATTACHMENTS:
Description Type
Ehlinger Claim Supporting Documentation
Gottschalk Claim Supporting Documentation
Hallman Claim Supporting Documentation
Leza Claim Supporting Documentation
Nowacki Claim Supporting Documentation
Shoellhorn Claim Supporting Documentation
Woods Claim Supporting Documentation
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CLAIi�l11 AGAlNST THE CITY OF DUBUQUE, IOWA ��.b��c: �"IC.S
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This written report constitutss your claim agains# the City of Dubuque, lowa. 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 W. 13th St., Dubuque, IA 52001. It
will then be referred by the City Cou,ncil to the appropriate departmenf for investigation. ;
Once that investigation is completed, a report and recommendation w.ill be submittecl to the
., ;
City Council. You will be provided with a copy of tha# report.and recommendation. . �
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THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE O.F �
THE C1TY OF DUBUQUE HAS THE AIJTHORITY TO MAKE ANY REPRESENTATION TO YOU ;a
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. ��
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1. Name of Claimant: ��G'L��` 7'�D�`tCcs' ft�Gt�k. �,� �� �-�u.�� YY�c�,n� �
2. Address: ��y . �. S� /V.•
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City: � �1��"`l�'"!ra�,' State: �� Zip: �2p�O '
3. Telephone Number: S6 3 " 2 s� -- J � 12 : .. �
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4. Date of Incident: 2- l o���SZ..c��� � , : : � . ' ��
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5. Time of Incident: ��'1?A ',�
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6. Location of Incident (Be specific): �'�12. '7 �CC'i Gt �,L' Ir1,r' nr't /Q1/��
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7. DESCRISE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. '(Give �
fufl details upon which you base your claim. If a City employee was involved, :give the !�
employee's name.) �
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5��, o� �l p�. � �,�r r� M: �'�r`l�� v���/'c<� , �
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8. What were weath�r conditions like? � ���. ' - '
9. Give name and address. of any witnesses: /"►,`ls� �x�' Gk+�^�'-r ���`�'""''������
10. Did police investigate? (If so, give names of officers.)
���� S��- � � � ��,� � � r 4 v � �r $� 1�'a�,13�� �
11. Was anyone injured? (If so, give names, addresses, and extent of injuriesj.
N�e .�,,�l�G .
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'12. Was any damage done to property? (if so, describe property and the extent of
damages. At#ach estimates of damages or describe basis for ascertaining extent of
damage.)
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13. What other damages do you claim, it any? ' �-S�F L-�F � S/�G�� !
C��rG.� �(,D�ffZS �v'�� G'e�h-- /'k./'r`���, . ',
'14. Have you been compensated for any part or all of your claim by any insurance '�
company? (If so, give name and address of insurance company and amount paid.)
,��/ �L�-�i�GrlZ' 6".�,_,S �.h 6e�e�,i� �'�ol.�/l���,
15. What amount do you claim frotr� the City of Dubuque? I�'�=
Ka�'� z`'o r �lc - 5'�c d�t� -,�� LL�S J" flz� �ite a� �''�y"w �s SS' @� �
.,�..i-�,.,f p���fF'�1� ,;
16. y d�o you cl�im the City of Dubuque is re ponsible? i
�t��- �sr�ct �'�d�.- a�r�,c�� ��3�, 2las�� � � .
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� 17. Have you mad� any claim against anyor�e else for damages as a result of this incident? �
(If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that source,
an�sa, in what amount?
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ua�ed ai t�u�uque, iowa this � day o� 1�'e� r'���'Y , 20�
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2r'�-'G��� l , �Ct l /r`1,.L;/L._ (Print Name) � r��-� �., f��
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(Rev. 5/18)
Confidential
This communication and any attachments rnay contain information_ which is confidential
and privileged by law and is for the use of the designated recipient. If you are not the
intended recipient, you are hereby nofiified that you have received this communication in
error, and that any review, disclosure, dissemination, distribution or copying of its contents
is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of �
your receipt of these items and desfiroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
�
Confidential information may include the following:
1) Social Security Number(s) 'j
2) Medical/Health Information ,
3) Personnel/Disciplinary Information �
4) Bank Account Information i,;
5) Financiallnformation I;
6) Credit Card Numbers ���
�
If any documentation you desire to submit to the City of Dubuque contains any of the items above �
this cover sheet must be attached directly to the confidential information and indicate the type of ;,
information that is included. �
;i
� �
. ,
�� , hereby certify that the attached documents '
include the following protected information:
�
Social Security Number(s) Bank Account Information �
Medical/Health Information Financial Information �
Personnel/Disciplinary Information Credit Card Number(s)
I understand that this information may be distributed within the City organization or to agents of the
City for processing and I hereby authorize the City to act accordingly taking all precautions to
- protect my information from unnecessary distribution.
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Signature Date