Claim, Schlueter, JeanCLAIM 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: Jean Schlueter
2. Address: 2668 Marywood Dr.
3. Telephone Number: 563 582 0368
4. Date of Incident: 8 14 01
5. Time of Incident: between 2:05 - 2:15 P.M.
6. Location of Incident (Be specific): In street in front of 2849 White
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.)
Got out of my car took two steps on second step went down street has lots of holes and uneven
places because holes
8. What were weather conditions like? Dry
9. Give name and address of any witnesses: None
10. Did police investigate? (If so, give names of officers.) No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Joan Schlueter cut palm of left hand, scraped side left arm before elbow
scraped side of left knee and bruised left hip.
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.)
None
13. What other damages do you claim, if any?
None
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.)
No
15. What amount do you claim from the City of Dubuque?
Chirocare Plus bill Dr. Bradley Brooks
16. Why do you claim the City of Dubuque is responsible?
Uneven street holes
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?
No
Dated at Dubuque, Iowa this 15 day of August, 2001 .
/s/ Joan Schlueter
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
The Claim must be filed with the City Clerk at City Hall, 50 W. 13m 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:
2. Address: c~/~
3. Telephone Number: -~'/-~
4. Date of Incident: ?//~/7////~ /
5. Time of Incident: ~ ~L~J ~- ~--- n
6. Location of Incident (Be specific):
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
8. What were weather conditions like?
9. Give~ name and address of any witnesses:
10. ~Did police~j~vestigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of/~ojtJries), i~
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.)
13. What other damages do you claim, if any?
14. Have you been compensated for any part or ail 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 damages as a result of this incident?
(If yes, give name and address.) v/,,
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 /,._~
(Rev. 1/00 & 7/01)
(Print Name)