Claim Ball RossCLAIM 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: Ross Ball
2. Address: 1298 Locust St Dubuque, Ia 52001
3. Telephone Number: 563 583 0794
4. Date of Incident: Last week of DEC - Firts week of Jan.
5. Time of Incident: during night
6. Location of Incident (Be specific): 1298 Locust St front sidewalk
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.)
snow plow cleard snoe in front of house around parking meters, and damaged 2 flower pots
8. What were weather conditions like? snowy
9. Give name and address of any witnesses: myself
10. Did police investigate? (If so, give names of officers.) no
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.)
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.) no
15. What amount do you claim from the City of Dubuque? $270.00
16. Why do you claim the City of Dubuque is responsible? Because it was a city employee who scoppend the pots up whild shoveling snow and damaged them
17. Have you made any claim against anyone else for damages as a result of this incident? no
(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 20 day of Jan , 2001 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE
This writtenreport 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--..endation 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 EM~LOYEE OF TM CITY OF DUBUQUE HAS 'l'~u~ AOT~0RITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE
PAID.
6. LoCat~.~ ~f incid'nt. (Be ~pecif~-5'' /~7~L~ ~
7. DESCI?.IEErACczDENT OU OCCUBRENcE'THAT CiUSED IN,sOKY OR OA,HA(~E;
(Give: f~l details upon:which you base-your~ cla~. If a City
~loyee was involved, ~ive the ~loyee's n~e.)
8. ~a, were:~ea,her conditions i~ke?
10. Did police investigate?
(If so, give names of officers.)
11. Was anyone injured?
injuries.)
(If so, give name, address and extent of
12. Was any dmm~ge done to property? (If .so, describe property
and the extent of damage. Attach estimates of d~m-ges 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 come, any? (If so, give name and address of
insurance compan~vand amount paid.)
15.
What amount do you claim from the City Of Dubuque?
16. Why~o you claim the City of Dubuque is responsible?
l?. aav~,.you mad-~ a,~,y..~laim against a~yome else for damagss as a
rss~lt of thzs ~¢~dent? ~
If yes, give name and address:
18. If the answer to Questi0n.~7_.is~ ~e~ ~aye you received any
.... paymeh2 fM6m:'2hat'~ou~ce, and if so, in. what amount?
Date~t' l~:u/Duque~- IOwa,
this. ~ ~ day of
(Revised January, 2000)
(Signature)
(Print Name)