Claim by Elizabeth Smith —/�41
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWAGo�"
This written report constitutes your claim against the City of Dubuque, Iowa. You K C`"z+-ft��
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 131h St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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: RZQ�., s rryHn
2. Address: j Bio EAtT k JIT C
3. Telephone Number� N'-9h
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4. Date of Incident: 3 N'-9h15 1c
5. Time of Incident: �K X. 9 Ron -tn aJRe=JQ. �b • 1JfJVh
6. Location of Incident (Be specific):
140 1 Ih rA 1-1 RP �LiS2-w�ej�"
7. Describe the 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.)
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8. What were wea er con itions like?
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9. Give name and addre s of any witnesses:
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Did police investigate? (If so, give names of officers.)
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11. W=one injured? (If so, ive names, addresses, and extent of injuries).
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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
e ent of damage.)
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13. What other damages do you claim, if any? r+na�lGtt�e FOR U° r
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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
a E� nt paid.)
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1at amount do you claim from the City of Dubuque?
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16. by doyou claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of
th_i� iOncident? (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,this -day of
(Signal re) 6 m n
Liz- Syyl; bh � m
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(Print Name) 0 = m
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Confidential
This communication and any attachments may contain information which is confidential
and privileged by law and is for the use of the designated recipient. If you are not the
intended recipient, you are hereby notified that you have received this communication in
error, and that any review, disclosure, dissemination, distribution or copying of its contents
is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical/Health Information
3) Personnel/Disciplinary Information
4) Bank Account Information
5) Financial Information
6) Credit Card Numbers
If any documentation you desire to submit to the City of Dubuque contains any of the items above
this cover sheet must be attached directly to the confidential information and indicate the type of
information that is included.
I, , hereby certify that the attached documents
include the following protected information:
Social Security Number(s) Bank Account Information
Medical/Health Information Financial Information
Personnel/Disciplinary Information _Credit Card Number(s)
I understand that this information may be distributed within the City organization or to agents of the
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
Signature Date
I have read the information above and do not have any confidential documentation to submit to the
Cit"f Dubuque as part of this Claim Against the City
5l 19 l �ot5
Signa re Date