Claim by Justin R. MillsCLAIM AGAINST THE CITY OF DUBUQUE, IOWA x/,
This written report constitutes your claim against the City of Dubuque, Iowa. You should I_I
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.
1. Name of Claimant: V STM/ R. .
2. Address: 32' o SOZoo, ... //ac s Pe 1706oaof .r 5" zoo Z.
3. Telephone Number: Sb3 • 5/3 • Z28's
4. Date of Incident: 7 /3 / // — g/3 //O
5. Time of Incident: L>lVxi(JOh/
6. Location of Incident (Be specific): 2'/81162ve jR /OAT Abeg try)
NCX T To f'Fxs TEE.— 4, cg.4 ,V,9N4.4+2,
6 °
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.) r
( p.,r/ of a%re..�f, 06019.4.7 p44 4 M .F Plc fire arrcr•.ff tdfooyb$ ■ ,
pg+hT` ouevseral C0Veve4 Mtn Zoid NoM04Accoc.a Avromodlt.F
8. What were weather conditions like? MC—e, SvNNY , (i t iv p
9. Give name and address of any witnesses: C-!+i„(ci.•.lcs)Pi c(cetibrock. j J dsi Qit4.ra/seh
•Y c•L3 ■ave, aS$. .ficcfe�.
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 property? (If so, describe property and the extent of
damages. Attach estimates of damages or describe basis for ascertaining extent of
damage.)
Y E5, QVELs,o,•. cove'eI 44 2oio
OE DETAILED by f:Fc.o< / d wax 44 f0 res4owc. over, f p a s.e# - ser-
a flitc.k.e 4 es 1$1440./.e. fr.w. Ali rat. tG Cur G4141s1. # /87. Zci
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.)
(Rev. 1/00 & 7/01)
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15. What amount do you claim from the City of Dubuque?
/6 7.5"
16. Why do you claim the City of Dubuque is responsible?
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C i 1) 4, . f.. r' Advs./ 4'� o' olfeJ over" 4 p /r•:.
17. Have you made any claim against anyone else for damages as a resuKof this incident?
(If yes, give name and address.) 410
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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Dated at Dubuque, Iowa this /0 day of Av, ✓S 1 , 20/0
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N. .)004 Ace oco; C4, marr
(Signature)
(Print Name) n °
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COMPLETE DETAIL:
$
MISCELLANEOUS:
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$
$
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$ / ,'"5 - - - -- •,c--. - r-D
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$
$
$
$
INSPECTED BY: '1 , /
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TOTAL
TAX
TOTAL
$ z 7_5
$ /,,,- ..5
$ ,,,t,f
Ticket #: 5675
255 LOCUST ST. 2090 HOLLIDAY DR.
DUBUQUE, IA 52001 DUBUQUE, IA 52002
PHONE: (563) 588-0185 PHONE: (563) 557-7822
Name: C.4-- Color: d e e. ze f. ., Date:
Year a make of auto: _e„, Stock #
Mirack Car Wash
Tracey L. Stecklein
Paralegal
Suite 330, Harbor View Place
300 Main Street
Dubuque, Iowa 52001 -6944
(563) 583 -4113 office
(563) 583-1040 fax
tsteckle@cityofdubuque.org
Justin Mills
3210 Brook Hills Dr
Dubuque IA 52002
imills(a flexsteel.com
RE: Possible Claim Against the City of Dubuque
Dear Mr. Mills:
Attachment
Dubuque
AN�dMxClh1
1� �►
2007
August 10, 2010
Very sincerely,
/ts
Tracey Stecklein
Paralegal
THE CITY OF
DUB
Masterpiece on the Mississippi
If you wish to file a claim against the City of Dubuque, we would request that you fill out
the attached claim form and mail it to the City Clerk's Office at the following address:
it" Ms. Jeanne Schneider, City Clerk
City Hall — City Clerk's Office
50 West 13 Street
Dubuque, IA 52001
Once the claim has been stamped in by the City Clerk, it will be forwarded to the City
Attorney's Office for investigation.