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Claim by Alec Lee Benson Copyrighted August 7, 2017 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Alec Benson for vehicle damage, Lester& Susan Bettcher for property damage, Linda Breitbach for personal injury, Charles and Ruth Ellis for property damage, Timothy Kelly for vehicle damage, Mark Lansing for vehicle damage, Monique Hopkins for vehicle damage, Aislinn O'Brien for vehicle damage, Lynn Pollock for vehicle damage, suit by Chris Cullen for Civil Service veteran's points application. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Benson Claim Supporting Documentation Bettcher Claim Supporting Documentation Breitbach Claim Supporting Documentation Ellis Claim Supporting Documentation Hopkins Claim Supporting Documentation Kelly Claim Supporting Documentation Lansing Claim Supporting Documentation O'Brien Claim Supporting Documentation Pollock Claim Supporting Documentation Cullen Suit Supporting Documentation Nod. CLAIM AGAINST THE CITY OF DUBUQUE, IOWA G1� � This written report constitutes your claim against the City of Dubuque, Iowa. You should �Id�'� 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 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. 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 JWILL OR WILL NOT BE PAID. 1. Name of Claimant: 2. Address: _`1 so 1 0t,e 3. Telephone Number: (56 3) w 4. Date of Incident: L29�17 5. Time of Incident: 1 526 , S,,)6 Pp 6. Location of Incident (Be specific): 66r clork- rj(, i 7. DESCRIBE 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.) AV/ m('10p5ed, rrny-�A Q)V-1 54ecl �019., (Ovr �Ie- . prove OWL plald H �,/t qj b) Tfer, 8. What were weather conditions like? armo, 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) 0'(5Q&k f d @V1,0 -'0119 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). ro 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.) CrEn 6A Cra e U/ . WO J'I AO 0L tom' eejl! 1*01 C L'UV1AOef-' Rti� lnl�or.�cpccAVV 13 i4 �r (�r 'Jcdoo� C rte $�2"33, 13. What other damages do you claim, if any? 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.) I What amount do you claim from the City of Dubuque? 0:2 1 Whydo you cl m the C' of Dubu ue is res onsible? j �l✓r y 1 q pLL �U�� . 9 � P �i �� I,r✓�r �BC1Sti 17. Have you made any claim against anyone else for damages as a result of this incident? (if es, give name and address.) 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? 4A Dated at Dubuque, Iowa this ] day of It 2017. I (Signature) Z (Print Name) (Rev. 7/12) r . r fi F PP k s Confidential This communication and any attachments may contain information which is confidential r and privileged by law and is for the use of the designated recipient. If you are not the intended recipient, you are hereby notified that you have received this communication in error, and that an review, disclosure dissemination distribution or copying eying of its contents is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of your receipt of these items and destroy the communication and any attachments immediately. Further disclosure of this information may violate state and federal restrictions. b i Confidential information may include the following: jl 1) Social Security Number(s) 2) Medical/Health Information 3) Personnel/Disciplinary Information 4) Bank Account Information u 5) Financial Information 6) Credit Card Numbers If any documentation you desire to submit to the City of Dubuque contains any of the items above, this cover sheet must be attached directly to the confidential information. Please indicate below the type of information that is included. b I, AEC, &7_-ija , hereby certify that the attached documents include the following protected information: Social Security Number(s) Bank Account Information Medical/Health Information Financial Information Personnel/Disciplinary Information Credit Card Number(s) I understand that this information may be distributed within the City organization or to agents of the City for processing and I hereby authorize the City to act accordingly taking all precautions to prot ct my information from unnecessary distribution. I Z ,12 . &&/�'O , W31117 Signature Date I have read the information above and do not have any confidential documentation to submit to the City of Dubuque as part of this Claim Against the City. 77/3/// 7— Signature Date a m