Claim, Kallenberger, AmberCLAIM 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
reco~unendation 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: Amber Kallenberger
2. Address: 1635 White, Apt. 3, Dubuque, IA 52001
3. Telephone No. 556 5301
4. Date of Incident: 5 13 01
5. Time of Incident: 8:30 P.M.
6. Location: Main St. in front of the Holiday Inn
Location of incident. (Be specific)
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE.
(~ive full details upon which you base your claim, if a City
employee was involved, give the employee's name. )
I was walking down Main St. & I thought it was going to rain so I looked up at the
sky at that time a pief fell from the street light and split my lip.
9. Give ~e a~d address of a~y witnesses.
Did police investigate? (If so, give n~es of officers.)
10.
11. Was anyone injured: Yes, Amber Kallenberg, 1635 White, Apt. 3 split lip,
tetanus shot, going to dentist for front right tooth.
Was anyone injured?
injuries. )
(If so, give name, address and extent of
12. Was any dnmage 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. What other damages 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 nmme and address of
insurance company and a~ount paid. )
15. What amount do you claim from the City of Dubuque? Medical & dental bills.
16. Why do you claim the City of Dubuque is responsible?
17. Have you mad~ any claim aga%nst anyone else for damages as a
resul~ of this incidenU? ~O
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, 16th day of May, 2001.
~ 0~'~
/s/ Amber Kallenberger
(Revised Januaz-f, 2000)
Iowa, this