Claim Hanten, CindyCLAIM 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: Cindy Hanten
2. Address: 1075 Kelly Lane
3. Telephone Number: 557 1381
4. Date of Incident: Early January
5. Time of Incident: Early AM
6. Location of Incident (Be specific): Home
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.)
While picking up garbage, the can was thrown back on to sidewalk in cold temp. & was cracked.
8. What were weather conditions like?
Cold - snowy
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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.)
Garbage can was cracked - now is not useable and is less than 6 mos. old
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?
A new garbage can
16. Why do you claim the City of Dubuque is responsible?
The garbage man throw the cans onto the sidewalk - the truck is on the other side of the street.
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?
Dated at Dubuque, Iowa this 30th day of January , 2001.
/s/ Cindy Hanten
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE
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 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
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 AOTnORiTY TO MAKE ANY
REPRESENTATION TO YOU AS TO Wk~THER YOIIR CLAIM WILL OR WILL NOT BE
PAID.
6. Location of ix~cident.. (Be specific)
7 ~ .DESCRIBE ACCIDENT OR OCCITRRENCB THAT CAUSED INJURY OR DAMAGE.
(Give full details u~n which yOU base your claim. If a City
employee was involved, i
g ve the employee, s name. )
8. What were weather conditions like? ~_~)[~/~ ~./~/
9. Give name and address of any witnesses.
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give name, address and extent of
12. Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of d~unages or
describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any?
14.
15.
16.
17.
Have you been~ compensated for any part or all of your claim by
any insurance company? (If so, give n~ane and address of
insurance comPany and amount paid.)
What amount do you claim from the City of Dubuque?
Why dO you claim the~ City o~ DubUque~is responsible?
Have you mad~ any ~laim against else for damages as a
result of th s imc den ?
If yes, give name and address:
18. If the answer to Question 17 is yes~ have you received a~y
payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa,
2001.
(Print Na~e)
(Revised January, 2000)