Claim by Kurt Becker_ - ~ n ,"
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Y OF DUBU UE IOWA ~
CLAIM AGAINST THE CIT Q ~~,~'~
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 or will not be paid.
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1. Name of Claimant: Kurt Becker
2. Address: 11420 Rupp Hollow Rd #26
3. Telephone Number (563) 542-3184
4. Date of Incident: 9-15-07
5. Time of Incident:
6. City Dog Park Grandview Ave Dubuque
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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.)
11.nWas anyone/i'njure~`~ (If so, givee nam , addressest, 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
extent of damage.)
13. What othef damag
dq you c aim, if any?
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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.)
15. What~mo~t
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responsible?
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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.)
18. If the answer to Question 17 is yes, have you received any payment fr~ th,~
source, and if so, in what amount? ~~ ~
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Dated this ' / day ~eCe~~ , 20~ ~ `~' ~
(Signature)
you claim,frorJ~ the ~ity of Dubuque?
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(Print Name)
INVOICE
Adams Pet Hospital
5875 Saratoga Road
Dubuque, IA 52002
563 582-5500
FOR: Kurt Becker
11420 Rupp Hollow Rd
Dubuque,tA 52001
Date For
Where Warm Hearts & Cold Noses Meet!
Printed: 12-24-07 at 9:19a
Date: 12-24-07
Account: 8170
Invoice: 69009
Qty Description
Net Price
Services by Jerry Adams, DVM
12-24-07 Buster 1 Nail Trim -Dog
J ~ 12-24-07 Diego
12-24-07
. Services by
1 Office Visit/Examination
20 Rimadyl 100mg Tablets*
~12-24-07 #5359
Old balance Charges
0.00 89.75
Check payment
Tax Payments
"2.76 92.51
11.75
38.50
39.50
-78.00
~----~
New balance
0.00
Adam Pet Hospital 1? ? ~--07
5 ti 7 5 Saratoga Road..
Dubuyuc, Ill S~OU2 S
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Owner: Kurt Becker Patient: Diego
Case No: 8170 Breed: Rottweiler Mix
Street: 11420 Rupp Hollow Rd Sex: Neutered Male
City: Dubuque Age: 3Y
Phone: 542-3184 Color: Red
This document lists procedures to be performed on Diego. This estimate only approximates the ::ost
of this visit. It does not include any treatments that may be deemed necessary upon examination
and commencement of the include treatments. You are responsible for all fees incurred during the
visit included or not on this estimate.
The following is a list of the treats and/or supplies expected to be required during this visit and their
approximate cost.
If you have any questions concerning this estimate please do not hesitate to ask.
Procedure or Dispensed Item Qty Charge
Orthopedic Pack 31.50
Major Surgical Pack & Supplies 31.50
Pulse Oximeter Monitoring 22,25
Aerrane Anesthesia - >1 hour 103.00
Cnnrial Ci~tNira Mwtc,riM! 1.i.vv
Securos Ortho Implants 27.00
ECG Heart Monitoring 22,25
Rimadyl Injection 21.00
Rimadyl 75mg Tablets 14 25.10
I.V. Catheter-Anesthesia 11.75
I.V. Fluids-Anesthesia 17.50
Total Protein & Hematocrit 10.00
Mini-Blood Chemistry (4)Panel 27.00
Blood Collection 7.00
Routine X-ray 80.50
Cran Cruciate Ligament Repair 370.00
Penicillin injection 21.00
Amoxi-Tabs 400mg 14 34.90
Morphine Injection 21.00
Ellman Radiowave Surgical Unit 30.00
Tax... 4.21
Total estimate charges... $931.46
Created: 12-24-07
Your signature below does not make you responsible for the charges listed above unless performed
on Diego.
I accept and agree to the terms of this