Claim by Tim BushmanClaim Form
http://www.cityofdubuque.org/index.cfrn?pageid=155#95_0
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Home Page :Departments : Ciri Clerk :Claims against the Ciri : Clalln For1T1
City Clerk ~, //;~ >ti'~ ~ I'~ Dubuque
First floor of City Hall, 50 W. 13th Street Ll
Phone: (563) 589-4120 ~~j
Fax: (563) 589-0890 ~G~ 1 ~ III
Hours: 8 a.m. to 5 p.m. Monday through Friday ~`..//
Email: lschneid(cacitvofdubuaue.org 2pp7
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 or will not be paid.
1. Name of Claimant: Tim Bushman
2. Address: 3197 Killarney Ct.
3. Telephone Number: ~ L_, ~ -- ~~ t~ ~ - ~ 2~.2
4. Date of Incident: ~~c_ °'Z 3
5. Time of Incident: ~ ~ -~~ - I / .. ~~ a~'yl
6. Location of Incident (Be specific): Kerper little past gas station heading to Fengler Street.
7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base
your cla/,i/m. If a City employee was involved, give the employee's name.)
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8. What were weather conditions like? L ~>~. ~'' C'o / C~i
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9. Give name and address of any witnesses: ~~ ~ Yv~ U14 [/Cc.:
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10. D~~id~~police investig/a~te? (If so, give names of officers.) /~ sc~
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11. Was anyone injured? (If so, give names, addresses, 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.)
1 of 2 2/25/2008 12:55 PM
Claim Form
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http://www.cityofdubuque.org/index.cfm?pageid=155#95 0
13. What other damages do you claim, if any? 1'V i -> %1 ~
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.)
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15. What amount do you claim from the City of Dubuque? ~/ _3 / ~-. 7 ~
16. Why do you claim the City of Dubuque is responsible? ~ ~ f `~1 St~t~,t.
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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?
Dated this ~- day of ~-C.h , 20~
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(Signature)
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(Print Name)
Home Paae :Departments : Ciri Clerk :Claims aoainst the Ciri : C~altll FOI'Ill
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tN~t•; '~itF C>i~cl.~ier~er Priv~~~y Str3temerrt Linking F?olicy Not_surq ~ tivhu t~ c<rrrt~~ct? cliclx l~vere
City Hall, 50 West 13th Street, Dubuque, Iowa 52001
2 of 2 2/25/2008 12:55 PM
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