Claim, St. Claire, RickyCLAIM 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 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.
1. Name of Claimant: Ricky St. Claire
2. Address: 812 2nd Ave SE Dyersville, Iowa 52040
3. Telephone Number: 563 542 0493
4. Date of Incident: Oct 15th, 2002
5. Time of Incident: around 1:30 in the afternoon
6. Location of Incident (Be specific):
On Dodge at the corner of Cedar Cross
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.)
We were both stopped on the light on Dodge. Light turned green. We both came throw I was in left hand turn lane. He in Right. We went thru and he came right over me and put me in the median on Dodge.
8. What were weather conditions like? Sunny
9. Give name and address of any witnesses: Heidi Miller
405 3rd Ave. NW #4 Farley, IA 52046 563 744 9071
10. Did police investigate? (If so, give names of officers.)
No police was called
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
Just the muffler on my 95 Dodge Neon
13. What other damages do you claim, if any?
None
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.)
No
15. What amount do you claim from the City of Dubuque?
200 to 300 to fix the car.
16. Why do you claim the City of Dubuque is responsible?
Because he was not looking and he ran me off the Road.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
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 Oct day of 21st , 2002
/s/ Ricky St. Claire
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLA,M AGA,.ST T.E C' V OF DUSUQUE, ,OW^ '
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.
1. Name of Claimant:
2. Address: ~'1~ ~'~c~
6. Location of Incident (Be specific): (~
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.)
8. What were weather conditions like? ~Y~%\/
9. Give name and address of any witnesses:
10. Did police investigate~f so, give names of officers.), ~
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.)
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(if yes, 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?
Dated at Dubuque, Iowa this ~' ' . day of ~1 ~-~
,20(~~L.
~ (Signature) ~
/ (P~int Na~me)
(Rev. 1/00 & 7/01)