Claim by Christopher Lange1 7 \ c7,;,1 1./ U""
LAIM AGAINST THE CITY OF DUBUQUE, ��
C UE, IOWA Q
This written report constitutes your claim against the City of Dubuque, Iowa. Y
should complete this form in full and attach any additional information that .
supports your claim. 1�'`�
The claim must be filed with the City Clerk at City Hall, 50 West 13 St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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: C i \ s ; U NE R v.
2. Address: 2605 FLI L 10/ S - 71Z E E T
3. Telephone Number 563- 581 - 6 386
4. Date of Incident:
5. Time of Incident:
AP)L Is, Zio
� =oo pry)
LIPOGE
6. Location of Incident (Be specific):
5 - FR I P o t - ( p 3 s f3E i w` N C u,M /WA S? EW/)LK
4A114 NT 7o Ft4L1 ,A) ST►2F T
7. Describe the 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.)
L4WAJ YVlowEf. RL/ E s 1 ctc LiAe
( 0 LT IA) G (2/}S5 . SEt f1-7T4C »F6 Pth7vs
8. What were weather conditions like?
FA-JR V
9. Give name and address of any witnesses: m ojE
10. Did police investigate? (If so, give names of officers.) '
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.) Il6/EA BL 6E 44/111)-GE/
13. What other damages do you claim, if any? 1 .
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.) n'
15. What amount do you claim from the City of Dubuque? `3
�5e_
PRheE QLWTE FRAM FLLIS E&u1M1EA1T FoR N wl QLh
16. Why do you claim the City of Dubuque is responsible?
W4 - 1k ►0�MATY JT �c,�l��RE� WA- MAN /-} )SS T)tE
STREET FRorn My PROP ATy . AJumERous 4MT IAL5 itJ f
M a
STOR�,D oA) '' 5) of STRR /} d /Id GRA -SS. LT li) OWESTION
W/ LEA 13)-1a1/4)45 _ Zt sh0u FMuE )3 /AI (IE)WVE1.
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.) f �
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
( gnature
C N R I5 ioP -f S. L4AJ
(Print Name)
t V.o JL / E M41P
is 3 Az day of ,4 t L , 20 D .
0
cr
- o
Invoice Number Quote
30551
C&T Lawn and Garden Comp Inc
DBA Ellis Power Equipment
3125 Cedar Crest Ridge
Dubuque, IA 52003
(563) 582 -1733 Fax (563) 582 -8909
Bill To
Cash Sale
Part Number Mfg Description
612543 -03 LB BLADE -20.88 INCH
We are looking forward to having you as a valued customer.
Customer Signature
Electrical parts cannot be returned.
Invoice Date:
PO Number:
Sold By:
Terms:
Tag Number:
Ship To
Unit Price Qnty Extended
$23.49 1.00 $23.49
Sub total:
7% ST Sales Tax:
Total:
Balance Due:
4/26/2010
Quote
$23.49
$1.64
$25.13
$25.13
Date Printed: 4/26/2010
Time Printed: 3:30 PM