Claim, Hirsch, DaleCLAIM 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 ~he 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 Tn,.' 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: Dale A. Hirsch (Nick)
2. Address: 1510 Hickson
3. Telephone 319 583 4410
4. Date. of Incident: 30 April, 01
5. Time of Incident: ~j,_ .~
6. Location of incident. (Be specifi,c)
What were weather conditions like?'"~ 0 ~/?
Give name and address of any witnesses.
7. Describe Accident: Window broken in topper on Truck - grass cutting,
flipped up rock.
10. Did poll, ce investigate? (If so, give names of officers. )
11. Was anyone injured? (If so, ~ive name, address and extent of
injuries. )/
12.
Was any damage done go property? (If so, describe property
and the extent of damage. Attach es=imates of damages or
describe basis for ascertaining extent of d~ma~ge.)
Window broken in truck.
13.
What o=her d~mages do you claim, if any?
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.)
15. What amount do you claim from the City of Dubuque? $175.00
16. Why do you claim the City of Dubuque is responsible? You cut the grass.
Have you made any claim against/~nyone else for damages as a
resul~ of this incident?
If yes, give name and address:
18.
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, this 10th day of May, 2001.
20
Dale A. Hirsch
(Revised January,
Iowa, this
2000)
' (Signat'ur~)
t Name~ '