Claim by Randy Miller~ ~~q ~ i
CLAIM AGAINST THE CITY OF DUBUQUE,
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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 13t" 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: !1 ~ `
2. Address:
3. Telephone Number S b~~ ~ D l ~~ ~ 1
4. Date of Incident: ~ 1' ~ ~D _~ ~
5. Time of Incident: I' ~~ C~,I' ~ Orrr1~~
6. Location of Incident (Be specific):
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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 emplo,~ree's name.) ~ __ i~ ~ _ a
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9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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8. What were weather conditions like?
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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 da~age.) / „1l 6w _ /
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13. What other damages do you claim, if any?
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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. hat amount do you claim from t e City of Dubuque?
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16. Wh do Xou claim the ity of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of
thi;~ cident? (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?
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Dated this day of ~(~r.wuf~ , 20~. ;~~~ ~ ~;
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Use Your ;~,~~ %„; 2%
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BIG CARD `°: ~~• REBATE
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MENARDS - DUBUQUE
5300 Dodgem 5t re~~et
Dubuque, IA 52003
KEEP VOUR RECEIPT
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RETURN POLICY VARIES BY PRODUCT TYPE
Allowable returns for items on this
receipt will be in the form of an in
store credit voucher if the return
is done after 04/19/09
III~I I I'I~I I I IIII'I II'II I~ III
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Sale Transaction ') I
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8" X 2' FURNACE PIPE
6393287 4.67
8" X 5' FURNACE PIPE
6393290 9.94
8" X 5' FURNACE PIPE
6393290 9.94
MOUNT LIGHT W/SWITCH
3469002 9.99
MOUNT LIGHT W/SWITCH
3469002 9.99
5"FLTNG IdNT BRSHD NC
2162823 5.99
5"FLTNG NNT BRSHD NC
2162826 5.99
5"FLTNG NNT BRSHD NC
2162822 5.99
5"FLTNG MNT BRSHD NC
2162821 5.99
5"FLTNG NNT BRSHD NC
~~6,2_829 5 99
3.5" BLK ON GOLD ALU
2155571 0.74
3.5" BLK ON GOLD ALU
2155568 0.74
3.5" BLK ON GOLD ALU
2155568 0.74
3.5" BLK ON GOLD ALU
2155652 0.74
ELITE POST MOUNT STA
2156922 13.9
ASK LT W/ SWNG
3471060 8.77
6LED TASK LT W/ SWNG *
3471060 8.77
6LED TASK LT W/ SWNG *
3471060 8.77
TOTAL
T•v aT ~1 .. 117.74
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