Claim by Albert A. WeidenbacherCLAIM AGAINST THE CITY OF DUBUQUE, IOWA ,.~~ , `~'!, ~':'' Page 1 of 2
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ~"F' ~ ~C
This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional
i~ormation that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13s' St., Dubuque, IA 52001. It will then be referred by the Cily 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 I.S MADE BY THE CITY COUNgL NO EMPLOYEE OF THE CIl1f OF DUBUQUE HAS THE AUTHORITY TO
MAKE ANY REPRESENTjA~TION TO YOU/BAS/TOIYVHETHER LYOUR CLAIM WILL OR WILL NOT BE PAID. ~ Q
1. Name of Claimant: Albert A. Weidenbacher
2. Address: 3257 Sheridan Road
3. Telephare Number. $ro 3 - S ~ 3 ~ ~5~~ -r--' - ~ "j°f
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4. Date of Incident: _ U ? - D 7 - 0 q - ~. 'a
5. Time of InckieM: _ .7 .` f70 A ~~ -
6. Location of Incident (Be spBciRc): ~ / ~ ~./ ~ r e ~ .n ~i o ~,~ ~
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give fuN details upon which you base your claim. ff a City
employee was involved, give the empbyea's name.) D
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8. What were weather conditions like? S~ ~ D~ / u S ~~-n ~: s Z G N .-, r e .-+-~ e .•-. fi~~
9. Give name and address of any witnesses: ~.Ql~_ -~~ ~ ~ ~ ~~
10. Did police investigste? {M so, give names of officere.) /1~0.
11. Was arryone injured? (If so, give names, addresses, and extent of injuries). yrJ,
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 damsge.)
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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.) „ /G
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15. What amount do you claim from the City of Dubuque? .Z pid~ ~ ,{~~ e w Y L
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18. Why do you claim the City of D/ubuque is resporaible? 6ccc,~S'e .v~~ >~n u c K w a S ~a~ /~~d , /i ~ii~ • nlc SDU Gl=
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17. Have you made any claim against anyone else for damages as a resuk of this inciderrt't yU ,
(If yes, give name and address.)
18. H the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? ,/~Q,
Dated at Dubuque, Iowa Mis ~_day of /7 v,, ceS ~ 20 G Q
hops://gw.cityofdubuque.org/gw/webace/ek2gveLa31w8didFg3/GWAP/AREF/3?action=A... 8/12/2009