Claim by Trigger Happy Tatto 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 any additional information that
supports your claim.
The claim must be filed with the City Clerk at City Hall, 50 West 13th 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 o-c will not be paiTAM
1. Name of Claimant: �dFpq /Ntg Vbpp(,o5Josoo Weiper�
2. Address: �►' �
3. Telephone Number 0� 04
4. Date of Incident:
5. Time of Incident: 6 n J1r,)
6. Location of Incide t (Be s ecific):
a Tel ho. re6m n pif
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 weather conditions like? 5gtd/ W03 theWr5 qmve seen
Given me and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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 dams esdo you claim, if any? (13oked60�)
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and Ne ar
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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
amount paid.) NO
15. What amount do you claim from the City of Dubuque? 00
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16. Why do you claim the City of Dubuqe is responseeble?
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17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
ated t is n` day of rah 20 I �„
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(Seg na re
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(Print Name) , --
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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 j
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 b
If an documentation you desire to submit to the Cit of Dubuque contains an of the items above
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this cover sheet must be attached directly to the confidential information and indicate the type of
information that is included.
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I, Nmu Vow; a . W ,_ hereby certify that the attached documents �{
include the following rotected infor ation:
Social Security Number(s) Bank Account Information
a
Medical/Health Information Financial Information
Person neVBiscipZq, Information Credit Card Number(s) !'
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unders and that this information may be distributed within the City organization or to agents of the a
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
Ni'gn
6 �ur �� Da e
I have read the information above and do not have any confidential documentation to submit to the
City of Dubuque as part of this Claim Against the City
Signature Date