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Claim by Frank Vans Evers, Jr.City of Dubuque ITEM TITLE: SUMMARY: SUGGESTED DISPOSITION: ATTACHMENTS: Description Furlong Claim Kilburg/Dubuque Dental Claim Lindecker Claim Loewenberg Claim Swain Claim Vans Evers Claim Copyrighted November 6, 2017 Consent Items # 2. Notice of Claims and Suits Renee Furlong for property damage, Brett Kilburg d/b/a Dubuque Dental for property damage, Deanne Lindecker for vehicle damage, Chris Loewenberg for vehicle damage, Martina Swain for vehicle damage, Frank Vans Evers for vehicle damage. Suggested Disposition: Receive and File; Refer to City Attorney Type Supporting Documentation Supporting Documentation Supporting Documentation Supporting Documentation Supporting Documentation Supporting Documentation CLAIM AGAINST THE CITY OF DUBUQUE, IOWA f'1\ 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 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 WILL OR WILL NOT BE PAID. Name of Claimant: cql\( 1. 2. Address: 3. Telephone Number: 4. Date of Incident: \-0 1( \ LA -P n, *6 (61K1A (S. fikA_ 6. Location of Incident (Be specific): J..cAAIR k`CAAI t-`' (jok.).1c doccr 1V\eDo.ns\ 5. Time of Incident: SLDO 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.) C6ar. s ve,(1/ C‘tAis Ii\o‘k -Prctd- RAI c\ iCk Cb)efeS . What were er conditions like? 0‘7,k* (v‘fU ocru 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) ‘S 90\ICt 00LJ -lac +old IOW un cc 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). 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.) f© 13. What other damages do you claim, if any? k\& 104\w§ -a, 01 q,cc_ vikkqr) ct tce- CeC 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.) 15 What amount co you claim fro the City of Dubuque? 16. Why do you claim the City of pupuqueis responsible? Mt tPc werr .p-k•ri ncot�) far,-teri. , 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) a d 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, Iowa this V day'`�` 2 q � of � � 0 i (Rev. 7/12) (Signature) CO \ c �, � � (Print Name) -71 „kgo, S.1/0 ft^ (2 piesl -fo 061Nr, orri..cqact „Jett 40. 047!/0'“.1_, tCC+c) scd- cte- 4 6‘.10 or, c+.4(r Pt-Fkr cecAkli\s \AP, A-kccc f 004 oc.c)‘ (i1, J!scNtcd veto h (ceco •\-1•Y-as rad' 1ci ij vJoki wAs Gico) Oc't 9 9.10 c„,1‘101 (A)erui 41,t3 GAO Gom_ 041- ig0 eOlcC, 344/0-1\ -T-ilf-ym 1 cce, (01A1-1, rNeJ, Ad in to 90\kc,<,i1v)mrc 1:Ac 41'c c‘iA \Oef\cA c\ccr) 4\of' ore,ArtoCgieL-tc Oic) -Ccc, ook tr) f R-6 fo 68Z- (0 006\ ckb\ye it\Ocv\c, OcA Ablcc DAIA EAT uy41. mccgctL, f\A Lcovtru) 4,4 In otc1C1 rjrce-/- 411C., 4-t Arlc Kt,C (1617 "\Uc- StY)C2-0 +0 6e, bqssed. „ gisu -*N1-c-cd (nc ccL ‘Ao -goo, LAks- 11601\ worii(n is3tAc otnolkr, are tAlt9S (9( ?reCe is 50 'IQ- fiC icfCVe40)) t91 )6(41e, 4\1 (1 0 01(04 of vwocibi Celth- OU/korIS corinci- UlqnC_ CeNi\N- k) OA I (1\f,bccJtkki3 Ler wcs (1-% ac.11c, ecA.1 cm on4Coovertini+ ivet"._Cr(c. Lf.kn 0,g-vc r uer-to r Confidential This communication and any attachments may contain information which is confidential 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 any review, disclosure, dissemination, distribution or copying 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. Confidential information may include the following: 1) Social Security Number(s) 2) Medical/Health Information 3) Personnel/Disciplinary Information 4) Bank Account Information 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 th.e type of information that is included. I, -4c.(\V.,- )(\ kto ( , hereby certify that the attached documents include the following protected information: Social Security Number(s) Medical/Health Information Personnel/Disciplinary Information Bank Account Information Financial Information Credit Card Number(s) I understand that this information may be distributed within the City organization or to agents of the City fo processing and I hereby authorize the City to act accordingly taking all precautions to protect y information from unnecessary distribution. I have read the information above and do not have any confidential documentation to submit to the City of Du Signa ue as part of this Claim Against the City. Date