Claim by Interstate Power & Light Company/ i
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. 13 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.
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1. Name of Claimant:
2. Address: 5 ,00
3. Telephone Number: 510 0 777 t
4. Date of Incident: b t , t [ ab I CJ
5. Time of Incident: t 1 : D 3
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6. Location of Incident (Be specific): W 11�
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?
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9. Give name and address of any witnesses:
10. Did police investigate? (If so, • 've names of officers.)
11. as anyone Mijured? (If so, g e names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages.
ch estimates of damages or describe basis for ascertaining extent of damage.)
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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.)
6
15. Wh amount do you claim from the City of Dubuque?
16. Why dg you cl he ity0 Du uq 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 1 j day of
(Signature)
GL 8e (Print Name)
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(Rev. 1/00 & 7101)
201
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Account Number
3006236212001
100989 - COST TO REPLACE POLE THAT WAS HIT BY A GARBAGE TRUCK ON WEST 3RD STREET ON 2/18/2010.
Description
INVOICE TOTAL
ALLIANT
ENERGY.
Interstate Power and Light, an Aliiant Energy Company
QUESTIONS CALL 1 800 - 255 - 4268
CITY OF DUBUQUE Invoice Number: 466278
925 KERPER BLVD Invoice Date: 03/03/2010
DUBUQUE IA 52001
ALLIANT
ENERGY.
Page 1 of 1
Interstate Power & Light Miscellaneous Service Billing
ACCOUNT NUMBER
3006236212001
SP 01 000008 53956 E 1 ASNGLP
i1l '1141 "11 1
CITY OF DUBUQUE
925 KERPER BLVD
DUBUQUE IA 52001 -2338
Keep this portion for your records
Return this portion with your payment
II111 "11' 'I' ' IIIIIIIIIIIII' illilll 'IIIIIIII'I'IIqId1"1IIIII
ALLIANT ENERGY
P.O. BOX 3066
CEDAR RAPIDS IA 52406 -3066
Amount
51,733.50
$104.01
51,837.51
6
I PAY THIS AMOUNT ON OR BEFORE 03/23/2010
$1,837.51
AMOUNT ENCLOSED
(IF DIFFERENT FROM ABOVE)
3006236212001001837510018375113
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