Claim by David Schroederrea. ~,[. ~tagtl IU:ZJAM G1~Y Ur uB~f ~t~a~ vEYI ~1a.119b P. t ~`
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CLAIM AGAINST THE CITY OF DUBUQUE,14,}~IA b
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This written report constitutes your claim against the City of Dubuque, Iowa. You s oul
complete this form in full and attach any additions) information that supports your claimm.
The Claim must be filed with the City Clerk at City Hell, 60 W.13"' St., Dubuquo, IA 6Y001. It
will then be referred by the City Council to the appropriate department for invastigation.
Once that investigation is completed, a report and recommendatbn will be submitbd to the
City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DEC1810N ON AI.L CLAIMS 1s 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: David J. Schroeder
2. Address: 2190 Stafford St.
3. Telephone Number: '~ ~~ ~ -1~~~
4. Date of Incident: ~~ 1 ~ ~ _
s. Time of Incident: ,~~, ~ ~ _
6. Location of Incident (8e specific): Corner of Stafford & Providence
T. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full dotath upon which you base your claim. If a City employee was involved, give the
empbyee's name.)
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8. What were weaker conditions like? =~~N'~~ ~ ~~n J~ "~
8. Give name and address of any witnesses:
10. Did police investigate? (If so, give nanres of offices.)
11. Was anyone injured? (It so, give names, addresses, and extent of injuries).
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1 ~. Was any damage don®to property? (If so, describe property and the extent of damages.
Attach estimates of dammges or describe bash for ascertaining extent of damage.)
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13. What other damages do you claim, ff any?
14. Have you been compensated for any part or all of your claim by any insurance
company? (lf so, give name and address of insurance company and amount paid.)
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16. Wha# amount do you claim from the City of Dubuque? ~~« ~~~
16. Wh rho you claim the City of, Dubuquo jis r+esponsibls?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, gins name and address.) ~~
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1 S. If the answer to Questbn 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated a buque, Iowa this day of ~~i ,_~_,_,, ZO • ~ ,
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TURPIN DODGE
90 KENNEDY ROAD
DUBUQUE, IA 52002
563-583-5781
ESTIMATE OF REPAIR COSTS
NAME
DATE a ; ~/" ~
YEAR c~ OCR `
MAKE ~~g Q G~~
MODEL
MILAGE
ADVISOR
TECHNICIAN
DESC B P TOTAL
vR
SUB TOTAL 7 -~o~l~
TAX
TOTAL ~ 07,. 8