Claim by John Davis Copyrighted
January 4, 2021
City of Dubuque Consent Items # 2.
City Council Meeting
ITEM TITLE: Notice of Claims and Suits
SUM MARY: ShelleyAtchison for personal injury; John Davis for vehicle damage;
Keith Dolan J r. for vehicle damage; Jeffrey Last for personal injury; Kevin
and Sue Leute for property damage.
SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney
DISPOSITION:
ATTACHMENTS:
Description Type
Claim by Shelley Atchison Supporting Documentation
Claim by John Davis Supporting Documentation
Claim by Keith Dolan Jr. Supporting Documentation
Claim by Jeffrey Last Supporting Documentation
Claim by Kevin and Sue Leute Supporting Documentation
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� � CL�41M AGAINST THE C1TY OF DUBUQUE, I�JWA � ���������'�� ��
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This written report constitutes your claim against the City of Dubuque, lowa. You should �
complete this form in full and attach any additional information that supports your claim. ,1
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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.
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THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF I'
THE CITY OF DUBUQUE HAS TFI'E AUTHORITY TO MAKE AlVY REPRESENTATION TO YOU i
AS TO WHETHER YOUR CLA1M WILL OR WILL NOT BE PAID.
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1. Name of Claimant: ,,� �
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2. Acidress: ��- ,� .. � �', � ��t �' �� �,!1
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City: ����',s��'`�� State: ��J��/ Zi ��' i
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3. Telephone Number: `��"; -� � �' l
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4. Date of Incident: �� �r � �,���°°`� �"� �, �r,� ,�
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5. Time of Incident: ����" �
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6. Location of Incident (Be specific): ,✓'� �,�� �
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give I
full 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 conditions like? �,�;;� � � �I
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9. Give nam� and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to propert ? if so, describe ro ert and the extent of �I
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damages. Attach estimates of damages or describe basis for ascertaining extent of '��
damage.) �+
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13. What other damages do you claim, if any? _ ,�r��i � �
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14. Have you been compensated for any part or all of your claim by any insurance ';�
co�npa�:y? �I#so, gh>� r�ar�e ar�� add�ess �f i�,sara�ce �ompa�y �nd amo�un� paid.) �
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15. What amount do , ou claim from the City of Dubuque?
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16. Why do yau clalm the City of Dubuqu is respc�nsible? i
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17. Have you made any claim against anyone else for damages as a result of this incident? �A
(If yes, give name and address.) a;
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'i8. 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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Dated at Dubuque, iovva this clay of , 2� G
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f✓' µ :� (Signature)
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