Claim - Burns, TracyCLAIM AGAINST THE CITY OF DUBUQUE
This w-ritten 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
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 WH~THER YOUR CLAIM WILL OR WILL NOT BE
PAID.
1. Name of Claimant: Tracy Burns
2. Address: 1600 Butterfield Rd. Apt. #`112
3. Phone: 538-4646
5. Time of Incident: 9:40 a.m.
6. Location: Highway 20 - Mile HIll - near construction site, driving west.
(Give full details upon which you base your claim.~
employee was involved, give the employee's
7. Describe accident: I was driving behind a City of Dubuque truck and a - what looked like a
big clump of mud - with a rock came flying out the back and hit my windshield. '
9. Give name and address of any witnesses.
10. Did police investigate? (If so, give names of off_~r,~, S o~ ~
11.
Was
anyone injured? (If so, give name, address an~ter~ of L!_
injuries. ) o
~ co
12. Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for as. certaining extent of damage.)
Crack in windshield starting to spider-out and worsen.
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 n~une and address of
insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
All IU want is my windshield repaired or replaced.
16. Why do You claim the City of Dubuque is responsible?
Your truck and this has happened numerous times and I am tired of
my car getting knicked up because your trucks are not being cleaned out fully and
properly.
17. result of th~s ~ncident? ~O0
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 -wznat amount?
Dated at Dubuque, Iowa, this 2nd day of June,
2001.
/s/ Tracy L. Burns
(Revised January, 2000)
(Print Name)