Claim Birch, Stacy
...- ....;.0/1412005 FRI .4:07 FAX 5635894342 Keyline Transit Cc-: ~002!003
(!HJ fA
CLAIM 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 lmy addillonallnformation that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th SL, 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 I'INAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE
OF THE CITY OF DUB.UQUE HAS THE AUTHORITY TO MAKE ANY REPREseNTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: ~-\o-L "I \b~ r ( ~
2. Addrelis: C;2:,C\;'j 'r\ \IC\'N..~~ \' ~ rr \~ ~ ';:l
3. Telephone Number: S~ '?:J - ~ 'r,'d - ~--:-tC::PJ
4. Date of Incident: ~ - do\.\ - ()"f")
5. TIme of Incident: d. '- d. \ ~) '\Y\ ,
6. Locationoflncident(Bespeclflc): Q,~~~"")~O""..Q. ~)(\ \.\!"1\-';G~' b~
\~\N..", \Nr-.. ~ ( r ~ ~,~""~ CJ ( t _,". -(.Jl).. .
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim.. If 8 City employee was involved, give the
e(T1ployee's name.)
f*o-.c-,,"\ \).,)\)...::, \A \~ \:,~ \"~IC\ -\~ W L~~R~ f'lr C''';CJ1~. 7-r\(A(\./
,
~ C.) tN'V"> \' ro ~~'\ ("",,), \,.x,,"', '\....~, 'vI \,,-?~-X c,,,,,\ ~i'\~ -\-\'fA1' he I(
\-,,~ ~\,,'<~. \~~ \( ,l.j'f1o,. \'<'\.i1~rl... ~\~ co C ~,\~~1f\ '~~ SC.!I,\L
or;, ~~A.~1i\\ \}..~iI.. "'::5'I"oJ.-'-\ \)0~-\('o,:ro,\,(lC-\_\.\.-'c() ~~. \-..~0,^,
8. Wh,~t_were weaifier conditions Iike?~ \t-.,\H"~l.r \lo."\(\", "'~,,)\.'''''''00~ \/'..\',:t~ '"
\:..~~ <;C\~ Go\' ' '
9. Give name and address ofany witnesses: ~ lA"", 'Stc.(:-':'<' ~'X\r~~ ~(Jr\'\r~
\
-:;.. ~o '(\6\ ~\.L r,,'00'-\ O\~~/, \f'\\-""",,1I2x~~1^
\
1 O. Old police investigate? (If so, give names of officers.)
~o2;(')...~F"'- '--:::. ~n~Y ~o...'~ ,~~~L'1 "\ ("...Yr\r rY\f/'~~ ~
11. Was anyone Injured'? (If so, give names, addresses, and extent of injuries).
'b\o-...C"\ S~\ ~\-..c,.~ ~\UC ~\<t.., ~v-.,,~ .
ov
,.
10/14/2005 PRJ ~:Oi FAX 56358943~2 Keyline Transit
. ,
Ii!; UOiiUUJ
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,lf any? ~orA \f-'~/,1<("", ~\\ ~,(,(\~~\CJ...'\\C~
. ~ ~
\;~\\ ~()0'--~\. ~\r-..~/( ~('J(~o-\ \t-.\~,'N.c ('~~s\i'6..\(') 'Y)~('J~
S(c~::;:'~~\T'<' ~\N."\ ~ \0Q~\,,,>v,{Cu- 'u,w"",,
14. Have you been eompensated for any part or all of your claim by any insurance
company? (If so, give name and address of Insurance company and amount paid.)
"0J\::'i _
15. What amount do you claim from the City of Dubuque? VO'c'-\"""'!{'\,-\ ~ry
,
~""'~\..:\~"""C ~ \J~\\
16. Why do you claim the City of Dubuque is responsible?
\l-..~~ "(0\\~ \('>('"' ""~1.,;'S~(),..",,,,(~.
\\..-Q,-"..M'-.{' ~. oo(,d~
\ T"',
17. Have you made any claim against anyone else for damages as a result of this Incident?
(If yes, give name and address.) '" "
\ 'o,J I:;)
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
_S~1ic
(SI9nat?:!
CO~kL 'f~
PrInt Name)
~~~~
~~""-\~~ y~\\~S
,20__.
K~CCD
',,)
(Rev. 1/00 &7/91)
.,".,)
.J