Claim, Avenarius, EleanorCLAIM A~AINST THE CITY OF DUBUQUE
Thiswritten 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
~eco~endation 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 A~T~ORiTY TO MAKE ANY
REPRESENTATION TO YOU AS TO WHETHER YOUR CLAtM WILL OR WILL NOT BE
PAID.
1. Name of Claimant: Eleanor Avenarius
2. Address: 10032 Boleyn Rd.
3. 319 582-6385
4.Date of Incident: 3/22/01
5. Time of incident: 10:55 A.M.
6. Location of incident: 2500 Central
7. Describe occurence: I was walking N. on Central when I tripped on an un-even
sidewalk, fell, landed on my shoulder.
8. Weather: sunny/clear
9. Give name & addresses of witnessess: Employee at Waukegon Color
Supply & unidentified driver.
10. Police investigate: Yes.
11. Injury: Dislocated L shoulder.
12. Damage done to property: No.
13. Other damages: N/A
14. Compensated:
15. Amount claimed from City: $1.741.00 medical bills (to date).
16. Why do you claim City is responsible: Sidewalk was damaged/uneven & evidently
previously reported to the City but never repaired.
17. Claim against anyone else: No.
/s/ Eleanor A. Avenarius.
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12. Was any d~unage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
13.
14.
What 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
insurance company and amount paid. )
15. What~ I~ ~am°unt/,03- do~dyou claim~from%{~ 'City~of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
result of this ~clde~t? /'-JO
If yes, give name and address:
If the answer to Question 17 is yes, have you received any
payment from that source, and if so, in what amount?
Dated at Dubuque, Iow-a, this day of ,
2001,
(Revised January, 2000)
(Signature)