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Claim Adler, EricCLAIM 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: Eric Adler 2. Address: 1217 Daynes Way, Sun Prairie, WI 53590 ` ++-++++++++++++++ 3. Telephone Number: 608 825 3811 4. Date of Incident: 8 24 03 (Sunday, Aug. 24 2003) 5. Time of Incident: Approx 7:45 P.M. 6. Location of Incident (Be specific): Flora Park - Big Slide, Penn Ave., Dubuque, IA 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.) Coming down the "big slide" at Flora Park, Eric hit his head (right side - corner of right eye required several stitches)... Knocked unconscious - A friend, Barry Sherman pulled him out of water. 8. What were weather conditions like? Clear Day 90 degrees 9. Give name and address of any witnesses: Barry C. Sherman, 1267 Hwy 35 N East Dubuque, IL 61025 /s/ Barry C. Sherman 747 7799 10. Did police investigate? (If so, give names of officers.) No 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Just - Eric Adler,1 217 Daynes Way, Sun Prairie, WI 53590 - Stitches & concussion 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.) Not to property - just Eric 13. What other damages do you claim, if any? None 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? E.R. room charge at Mercy Hospital Dubuque & physicians fees. 16. Why do you claim the City of Dubuque is responsible? City property 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 25th day of August , 2003. /s/ Eric Adler (Signature) (Print Name) (Rev. 1/00 & 7/01) 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: J~ ~ © ~-- 3. Telephone Number: &(~(~' <~;~--- ~.~ ~; ~ ( 4. Dateoflncident: ~ ~c/~ ~~ ~ ~c/ ~O~ ~ 5. Time of lncident: ~o~ ~.' ?~- ~ / ~ 6. Location oflncident (Be specific): ~q ~ ~ {~ ~/~ ~ 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.) ~ ' ~ ~ ~ ~ ~, -~ ~1 ~ ~ 8. What were weather conditions like? '(~1~_ d V ~. ~k/_ ~O . O ~- O~ 9. Give name and address of any witnesses: ,~ ~ k ~ ~ y ~& ~ ~ 10. Did policeinves;ate? ,lf,o.'give names o, officer4 ~ ~z/~ ~¢ ~' 11. Was anyone injured? (If so, give names, addresSes, and extent of inj~ies), l~ 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of dam .~es or describe basis for ascertaining extent of damage.) 13. What other damages do you claim, if any? 14. Have you been compensated ~or any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.) 15. What amount do you claim fro~m the City of Dubuque? 16. Why do you claim/the City of Dubuque is responsibl~ 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) \~ D~ 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 day of (Rev. 1/00 & 7/01)