Claim by Dennis AvenariusClaim Form
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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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.
1. Name of Claimant: Dennis Avenarius
2. Address: 10148 Dixie Dr .
3. Telephone Number: 563 583-1323
4. Date oflncident: Friday, 12 28 2007
5. Time of Incident: 6 PM
6. Location of Incident (Be specific): Wacker Dr, entran .e o K nn dy Mal ~ near DB&T Bank
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.)
My wife and I were southbound on JFK in the inside lane. I turned right
nntn Wa ker Dr still remainigg in the inside lane, and struck a large
pothole in the intersection. The pothole was in the intersection near the
B. What were weather conditions like? Rnarl_w~r ~~ac cn~,.,~ ~rkp~ (continued On Other
side)
9. Give name and address of any witnesses: Wife , Dixie Aven a r i u s
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.)
Left front tire was dama ed beyond repair and needed to be replaced and
front end need to be aligned.
13. What other damages do you claim, if any?
http://www.cityofdubuque.org/printer_friendly.cfm?PageID=155 1/2/2008
#7 continued: Kennedy Mall entrance to DB&T. There was a very loud bang and
by the time we reached Wacker Dr. and Hwy. #20 the left front tire
had gone flat. We proceeded to the parking lot at Target and called
Beidler Towing to tow the vehicle to Tandem Tire on Stoneman Rd. for
repairs.
Claim Form
Page 2 of 2
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? ..$260.20
16. VVhy do you claim the City of Dubuque is responsible? T~jarP Shnii 1 rl not h~vP keen d
^othnle of this size in the travel portion of the roadway.
17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name
and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what
amount?
Dated this 7th day of ,laniiar~ , 20_Q$.
(Signature)
Dennis Avenarius
(Print Name)
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http://www.cityofdubuque.org/printer_friendly.cfm?PageID=155 1 /2/2008
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