Claim by Merlyn Atkinson Copyrighted
January 3, 2018
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Merlin Atkinson for property damage; Amanda Loeffelholz
for vehicle damage; Molly Skoglund for vehicle damage;
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description Type
Atkinson Claim Supporting Documentation
LoeffelholzClaim Supporting Documentation
Skoglund Claim Supporting Documentation
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, lowa. 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. 13t" 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:__ /E'� � ��y N .���/�-S�i'�
2. Address: /�/6 �}/�7�'Gf�1- ���U�
3. Telephone Number: ��� j��'� ��� �
4. Date of Incident:__��-� -2� � 7
5. Time of Incident: ���L � /��C`/���i��'—
6. Location of Incident (Be specific): ���(�� �'� �C �� ��/�Z'�
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.)
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8. What were weather conditions like? G'���� I�
9. Give name and address of any witnesses: /���i '�' ',
10. Did police investigate? (If so, give names of officers.)
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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 do�e to properfiy? {If so, describe praperty and t�e extent c�f d�mages.
Attach estimates of damages or d��cribe basis far ascer�ain�ng e�ctent of darrnage.}
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�13. What crther dar�ages do you claim, if ar�y? /��.�"
94. Flave you been compensafied for any part c�r all af ycaur claim by �r�y ir�surance
comp�ny? (Nf.sv, giv� name and addre�s of insurance ca�mp�ny and amour�t paid.)
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°15, V9/hat amount do you clairre fror� the City of Dubuque? ����� �
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16. VIPhy do you� clair� th� City c�f Qubuque is responsible? �-��"�' ��'� �`�-�- �
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17. Have yc�u made any claim �gainst anyane else for d��nages as a result of this ir�cident? �
{If�es, give narr�� ar�d addres�,� f � �
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18. If the a�tswer to Qc�estiQn 17 is ye�, have yoc� received any �ayment #rom that source,
and if so, in what amo�ant?
Dated at Dubuque, lowra thi� ,�,. � d�y of ����"�'�,'�� , 20�.
(Signatur�) �"� �
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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 I
4)Bank Account Information l
5)Financial Information '�'
6)Credit Card Numbers Ii
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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 and indicate the type of �
information that is included. '�
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I, /� , hereby certify that the attached documents
include the following protected information:
Social Security Number(s) Bank Account Information
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Medical/Health Information Financial Information '�
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Personnel/Disciplinary Information Credit Card Number(s) �
I understand that this information may be distributed within the City organization or to agent's of �
the City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
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Signat e Date
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