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City Clerk ~~
First floor of City Hall, 50 W. 13th Stror:t
i'hone:(563)589-4120
Fax: (563) 589-0890
Hours: 8 a.m. to 5 p.m. Monday through Friday
Ernail: jschrteid~cityofdubuque.org
CLAIM AGAINST THE CITY OF I7~UB000E, IOWA
7 his 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 13ti' 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 roCOmmpndatlon.
1 ho 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: S"'r~ ~~QS ~[n!,/~ ~j l}r~7c~
2. Address: „~ r)~]'~- ~1 CrQyS fM ~ ~r _ ~ t{~ c rl ~ r' L try C- ('L~, -__
3. Telephone Number: ~~3-~ri(~ -(~~~~~------•--....._~~~~~~_~3..!~..... ... .
4. Date of Incident: '~I ' jj O8._ __ __
5. Tirne of Incident: ~~' !4(14,Y.
8, Location of Incident (Be specific): U~J~aEEs~n kNa ~~azu~~
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 emp//loyor.'s name.)
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8. What were weather conditions like? U~ rq
9. Give name and address of any witnesses: ~++~~.______..___..._ .....
10. Did police investigate? (If so, give vamps of ofNcers,)
,, yWas anyone injured? (If so, give names, addresses, and extent of injuries,)
12. Was any darnage done to property? (1f so, describe property and the extent of damages. Attach estimates of
damages or describe basis for ascertaining extent of damage.)
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13. What other damages do you claim, if any? _ Nr,~l~ __
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, givo name
and address of insurance company and amount paid,)
15. What amount do you claim trom the City of Dubuque? _._...
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i6. Why do you claim the City of Dubuque is 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.}
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18. If the answer to Ouestiort t 7 is yes, have you received any payment from that source, and if so, in what
arnou nt?
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