Claim Sheldon, JenniferCLAIM 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: Jennifer Sheldon
2. Address: 2734 Jackson
3. Telephone Number: 563 557 9037
4. Date of Incident: April 16, 2003
5. Time of Incident: 9:50 P.M.
6. Location of Incident (Be specific):
Big 10 Conoco on Central and W. 7th
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.)
Arrest and car impound
8. What were weather conditions like? not applicable
9. Give name and address of any witnesses:
Police Department
10. Did police investigate? (If so, give names of officers.)
Yeah
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.)
Confiscated clothing, ripped apart stereo, broke glove compartment, confiscated money, took knife, tore back set to the trunk out, popped tires.
13. What other damages do you claim, if any?
No
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? $645.18
16. Why do you claim the City of Dubuque is responsible?
taken out our custitie at time of arrest
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 29 day of April , 2003.
/s/ Jennifer Sheldon
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM 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:,~-~X~r~
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Inciderlt (Be specific):
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE.
full details upon which you base your claim. If a City employee
employee's name.) _~C~_~;~__ (~_Y~<2~ ~(~1~
8. W~weather conditions like~
(Give
was involved, give the
9. Give name and address of any witnesses:
10, Did pollce inv.estigate? (If 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?~/o q~, ~<~'
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
- ' (~j-nature)
(Print Name)
(Rev. 1/00 & 7/01)
DPD 08-01-97 DUBUQUE POLICE DEPARTMENT PROPERTY IN CUSTODY
6. PurpOse for Which Obtained
,/ Complaint Filed/
Evidence I~ Safekeeping Found Pending Other
7. Owner or Persons~Having on Interest in the Property and a Right to File a Claim (with address)
NAME DOB: ADDRESS PHONE
$. Items I HAVE PLACED THIS PROPERTY IN A PLACE OF SAFEKEEPING FOR TRANSMITTAL TO THE.DEPARTMENT PROPERTY
List OFFICER. I HAVE GIVEN A COPY OF THIS FORM TO Ab A RECEIPT.
A Thru Z Quantlh/ DESCRIPTION OF ARTICLE - LOCATION WHERE FOUND
, ~ ~ - -,-- . , ~ (~j
. . ~ / - :. ~ ~ · ~
9 Date, / ~i~s) Name ffyp~ pr PrJnte~ Baflge No. /~/] Officer(s) Signatu(e ~0. Receiving Locke~ No.
.... , , -- ~ ~ : ~. . ,
-il. ~i".~."~mStorogeNo. / 4278:'99
12. Seized Property Order Requested
Date
S.P. or S.W. Order No.
MARK ALL-iTEMS FOR FUTURE IDENTIFICATION CUSTODY CHAIN ON REVERSE SIDE
DPD 08-01-97 DUBUQUE POLICE DEPARTMENT PROPERTY IN CUSTODY
2. Case No 13 Case Date
4 Pe~on Pr~er~W~ Tak6n From or/R~e v~ From J ~ ~ ~ ~'- ~ / ~ ~ I
, ...,..
6. Purpose for Which,~lbtain~:l
j Complaint Filed/
Evidence [,/' Safekeeping Found Pending
7. Owner or Persons Having an Interest in the Property and a Right to File o Claim (with a~dress)
Other
PHONE
8. Items I HAVE PLACED THIS PROPERTY N A PLACE OF SAFEKEEPING FOR TRANSMITTAL TO THE DEPARTMENT PROPERTY
List OFFICER. I HAVE GIVEN A COPY OF THIS FORM TO ' AS A RECEIPT.
9. Date / ~ff cer(s) N~me ~yped ~ Printed), Badge No. ?? Officer s) Sigpat~re · ~0. Receiving Locker No,
12. Seized Proper~y Order Requested
Date
S.P. or S.W. Order No.
MARK ALI. ITEMS FOR FUTURE IDENTIFICATION CUSTODY-CHAIN ON REVERSE SIDE
DPD 08-01-97 DUBUQUE POLICE DEPARTMENT PROPERTY IN CUSTODY
I. Date 2. Case NO, 13. CoseDate
6. PurpOse for Which Obtained Complaint Filed/
Evidence Safekeeping Found Pending Other
?. ~rwner~r:P~rsonS Having an Interest in the Property and a Right to File o Claim with address)
N~AE DOB: ADDRESS
PHONE
8. Items IHAVE PLACED THIS PROPERTY N A PLACE OF SAFEKEEPING FOR TRANSMITTAL TO THE DEPARTMENT pROPERTY
List OFFICER I HAVE GIVEN A COPY OF THIS FORM TO AS A RECEIPT.
A Thru Z Quantity ' DESCRIPTION OF ARTICLE - LOCATION V~HERE FOUND
=.===.= ......... , ~ ..... -' ~ L_ : _'" >
,. ~.,~.~..~,,o,...~. ,.' 0260 -00~
12 Seized Pr oper ty Order Recluested
S.P. or S.W. Order No
Dote
MARK ALL ITEMS FOR FUTURE IDENTIFICATION CUSTODY CHAIN ON REVERSE SIDE
DPD '08-01-97 DUBUQUE POLICE DEPARTMENT
4. Person Property Was Taken From or Received From
2. Case No.
'7'
PROPERTY IN CUSTODY
3. Case Date ,2'
6. Purpose for Which Obtained
~ Safekeeping Found
Complaint
Filed/
Pending Other
?. ~/fi~r"~r Persons Having an Interest in the Property and a Right to FiJe o Claim (with address)
NAME DO~: ADDRESS PHONE
8. Items I HAVE PLACED THIS PROPERTY IN A PLACE OF SAFEKEEPIN~/R TRANSMITTAL TO THE DEPARTMENT PROPERTY
List OFFICER. I HAVE GIVEN A COPY OF THIS FORM TO AS A RECEIPT.
A Thru Z Quantity DESCRIPTION OF ARTICLE - LOCATION WHERE FOUND
9. Date B~ge o. ~ .Offi~ignature
~ficer(s) Na~e ~yp~ 0r Printed)
,,. 2363 -00:
12. Seized Propert~ Order Requested
S.P. or S.W. Order No.
MARK ALL ITEMS FOR FUTURE IDENTIFICATION CUSTODY CHAIN ON REVERSE SIDE
DPD 08-01-g7 DUBUQUE POLICE DEPARTMENT
PROPERTY IN CUSTODY
2. Case No. 3. Case Date
Person Proper~ Was Token From or R~eiv~ From
L~ation Where Obtained. Be Specific - Address - Vehicle with Lic. No. - Pers~
Complaint Filed/
Pending Other
6. Purpose for Which Obtained
8. Items I HAVE PLACED THIS PROPERTY IN A PLACE OF SAFEKEEPING FOR TRANSMITTAL TO THE DEPARTMENT PROPERTY
A Thru Z Quantity DESCRIPTION OF ARTICLE - LOCATION WHERE FOUND
11. Evide~eR.mStora~ No. 0 ~ T ~ '00~
~12~.~ S~fzed Property Order ReCluested
Date
S.P. or S.W. Order No.
MARK ALL ITEMS FOR FUTURE IDENTIFICATION CUSTODY CHAIN ON REVERSE SIDE