Claim, Lemmer, RalphCLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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 W. 13th 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: Ralph Lemmer
2. Address: 2417 Jackson
3. Telephone Number: 582 6323
4. Date of Incident: 6 05 01
5. Time of Incident: 7:15 A.M.
6. Location of Incident (Be specific): 2417 Jackson
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.)
At 7:15 A.M. I heard City Truck approaching our area. I looked out the window to see which truck and the driver
lumbered out of the truck and slammed into the antenna on our car. By the time
I got out the door he was several doors down and when I hollered at him he denied that he did it.
8. What were weather conditions like? Ra
9. Give name and address of any witnesses: myself
10. Did police investigate? (If so, give names of officers.)
Yes, Jon V. Berkly, Badge 84 & Supervisor ???
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No.
12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.)
Car Antenna
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 name and address of insurance company and amount paid.)
None
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
Self Explanatory
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
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, Iowa this day of , 20 .
/s/ Ralph Lemmer
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM 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
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. N~une of Claimant:
2. Address:
3. Telephone ~er:
4. Date of Incident:
5. Time of Incident:
6. Location of incident.
DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE.
(Give full details upon which you base your claim. If a City
employee was involved, gi~ve the employee's name.)
~at were weather con~c~ons ~ne? ~ ~
Give name and address of any witnesses. /~ ~-& ~,
10.
11.
Did police investigate? (If so, give names of officers.)
Was anyone injured?
injuries.)
(If so, give name, address and.extant of
12. Was any d~mage done to property? (If so, describe property
and the extent of damage. Attach estimates of dan~ages 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 name and address of
insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17.
Have you made any claim against anyone else for d~mages as a
result of this incident? /J~
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, Iowa, this
2001.
'day of
~ Signature)
(Print Name)
(Revised January, 2000)
VICTORY
21524
Dyersville, IA 52040 DATE
ADDRESS SALES~~ CHARGE
QU~T~ PART NUMBER DESCRIPTION LIST PRICE NET PRICE TOTAL AMOUNT