Claim Maiden, CassieCLAIM 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: Cassie Malden
2. Address: 825 Euclid
`
3. Telephone Number: 563 556 3403
4. Date of Incident: Aug 6 2003
5. Time of Incident: 1:30 P.M.
6. Location of Incident (Be specific):
2491 Jackson, in street they had it dry out between the sidewalk to street. No yello caution tape.
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.)
was in use no sign at all.
8. What were weather conditions like? Good
9. Give name and address of any witnesses: Mr. Link (Link Upholstery) 24th & Jackson. Mary Malden, 825 Euclid
10. Did police investigate? (If so, give names of officers.) Yes
I think Bade #65
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Cassandra Maleden, 825 Euclid, Dubuque IA 52001 Knee & Elbow
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.)
No
13. What other damages do you claim, if any?
Just the doctor bill I have no insurance.
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?
all $80.00
16. Why do you claim the City of Dubuque is responsible?
They left a open hole, no caution tape or barricades, was in use but after they get the call they filled it with dirt.
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 19th day of August, 2003.
/s/ Cassie Malden
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
This written report constitutes your claim agains e i y o ubuque, Iow~. 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:
Address:
3. Telephone Number:
4. Date of Incident:
5. Time of lncident: / 7 ~ ~ P, /~
6. Location oflncident (Be specific): ~ ~ ~ / ~ ~.~ .~ ~ ~
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?
9. Give name and address of any witnesses: ~ //., ~/~ (/'~
11~. -D, id, poli,ce i,r)ve?tigate? (If s~_o~ give names of officers.)
11. Was anyone injured. (If so, give names, addresses, and extent ot 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
company?
by any insurance
(If so, give name and address of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
(If yes, gi~e n~me 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?
Dat at bu Iowa
this
~ '- -(Sig n~lt-ure) '-"
(Print Name)
(Rev. 1/00 & 7/01)