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Claim Criss, MaryCLAIM 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: Mary Criss 2. Address: 752 Cottage Place ` ++-++++++++++++++ 3. Telephone Number: 563 557 2647 4. Date of Incident: September 9 2003 / August 28, 2003 5. Time of Incident: 1:00 P.M. 6. Location of Incident (Be specific): Senior - Dubuque High 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.) At Kaufman St. when my 11 year was choked by a man cause he was black and the DARE Officer said that he want me and my family locked up 8. What were weather conditions like? Its dark and hot 9. Give name and address of any witnesses: Noel McCary 750 Cottage Place and we went to what was the problem 10. Did police investigate? (If so, give names of officers.) No they only took the white people side 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). My son neck was bused 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? No I want the police to leave my faily alone start treated people the same 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? I don't no why my family are being target Cause we are black 16. Why do you claim the City of Dubuque is responsible? Cause your office are raceist copy and the missed treat black people because of they color. 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 10 day of September, 2003. /s/ Mary Criss (Signature) (Print Name) (Rev. 1/00 & 7/01) CLAIM 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. Name of Claimant: 2. Address: 3. Telephone Number: .~o.'~ [ ~-~-2 I / 4. Dateoflncident: ~-~'¢v~c q ~__oo~_~ ~ / ~,L~(~c~- ? p J , , ~) ! - 5. Time of Incident: I , © © ~ r~ 6. Location of Incident (Be specific): 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. full details upon which you base your claim. If a City employee employee's name.) 8. What were weather conditions like? (Give was involved, give the 9. Give name and address of any witnesses: f~6~ \ V.~ c C'Or ~Q ~ 5 o 10. Did police investigate? (If so, give names of officers.) 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). 12. Was any damage done to property? (If so, describe property and theextent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) 13. What 0ther damages do you claim, ifany? f.~© -~ ~r T-~-~ f~(.~ ~ ~c~ 14. Have you been compensated for any pa~ 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 from the City of Dubuque? '._L---~,~/d ~/-f ' J ' 16. Why do you claim the City of Dubuque is responsible? ('~(:X ~ % ~ tJ (~a Y' 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name 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? Dated at Dubuque, Iowa this I C) day of ~L~gnature) (Print Name) (Rev. 1/00 & 7/01)