Claim by Donna Sindahl Copyrighted
April 1 , 2019
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUM MARY: Adrian Appelman for property damage, Wade Duncan for
vehicle damage, C. Dennis Gansemer for vehicle damage,
Donna Sindahl for vehicle damage. Francis J. Ward for
vehicle damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City
Attorney
ATTACHMENTS:
Description Type
Appelman Claim Supporting Documentation
Duncan Claim Supporting Documentation
Gansemer Claim Supporting Documentation
Sindahl Claim Supporting Documentation
Ward Claim Supporting Documentation
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA J �\��rn���
This written report constitutes your claim against 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. 13t" St., Dubuque, IA 52001. It
will then be referred by the City Council to the appropriate department for investigation.
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: �j ('� � 1'� �°(„ j h �,�. `�� �°-��
2. Address: �1 �..� � Y`j J � ' ,h p � ��, .
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City: � � State: � I"7
Zip: � r�� j
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3. Telephone Number: � �" �� �' '� � �� �
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4. Date of Incident: ,�-y� ��-�.� I''
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5. Time of Incident: �d/�'} ��
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6. Location of Incident (Be specific): __,/!�(�/�„�► (} � ����, f� j� . �
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[�7. DESCRIBE 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.) ��
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�c�s �4��€ �vil�.
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8. What were weather conditions like? _ IJ (,j /�,1�-�, � ,�,/�-� s`/�,l G
9. Give name and address of any witnesses: %0/�
10. Did police investigate? (If so, glve names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of i
damages. Attach estimates of damages or describe basis for ascertaining extent of '
damage.)
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13. What other damages do you claim, if any? __/�(�;�� �
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14. Have you been compensated for any part or all of your claim by any insurance �
company? (If so, give nam� and adciress of insurance company and amount paid.) �
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15.,rl(Vhat amount do you claim from the City of Dubuque?
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16. Why do�o clafm the C�ity of Dubuqu�s responsible? � n � ���� I
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If y��ive name and address.) I
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18. If the answer to Question 17 is yes, have you received any payment from that source, �
and if so, in what amount? �� i
Dated at Dubuque, lowa this � day of 'l ��/�1�1 , 20�. �
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G�YI�- �� (Signature)
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(Rev. 5/18) :� =t � �
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Confidential
This communication and any attachments may 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 notified 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 destroy the communication and any attachments '
immediately. Further disclosure of this information may violate state and federal �
restrictions.
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Confidential information may include the following: �;
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1) Social Security Number(s) � � �
2) Medical/Health Information '�
3) Personnel/Disciplinary Information �{�
4) Bank Account Information `i
5) Financiallnformation
6) Credit Card Numbers � ���
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If any documentation you desire to submit to the City of Dubuque contains any of the items above �i
this cover sheet must be attached directly to the confidential information and indicate the type of ��
information that is included. ij
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I, , hereby certify that the attached documents >,�
include the following protected information: ��
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Social Security Number(s) Bank Account Information �
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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.
Signature Date