Claim by Lola Volkerty
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LAIM AGAINST THE CITY OF DUBUQUE, IOWA
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his written report constitutes your claim against the City of Dubuque, Iowa. You
'~ ould complete this form in full and attach any additional information that
~~supports your claim.
- ~ he claim must be filed with the City Clerk at City Hall, 50 West 13th St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
~; ~~ rr` investigation and to the City Attorney's Office. Once that investigation is
;Qcompleted, a report and recommendation will be submitted to the City Council.
,~ You will be provided with a copy of that report and recommendation.
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h r ~' 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: ~Lola Volkert
583 Jefferson Street
Across from Boys Club on Locust
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`~~ ~~ 2. Address: '~
~.f~ ~ t 3. Telephone Number ~~~ 7- ~ 7" / ~
~ ~ l 4. Date of Incident:
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5. Time of Incident:
`~ 6. Location of Incident (Be s ecific):
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7. Describe the accident or occurrence that caused injury or damage. (Give full
G~ 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 conditionv s Tike? ~ r
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name and add ^ess of any witnesses:
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11. Ways anyone injured? ~f so, g eve names, addresses, and extent of inju
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.)
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13. What other damages do you cla
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~i4. 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 yo laim from the City of Dubuque? jI ~! /~
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16. Why do you claim the City f ubuque irresponsible? ~!'~~ `~
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17. Have you~~any claim against anyone else for damages as a resr~of `"
this incid (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?
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