Claim Martens, Paula /~5~-~/~//:~CLAIM AGAINST ,THE CITY OF DUBUQUE, IOWA, ~Cc~gc~A~b ,,
This written report constitutes'your claim aga,nst 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 t.h.e City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52~t.O
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: Pt~I.t~ ~a/F~+'~k.~
2. Address: D lO lSi/J0n .S ec
3. Telephone Number: .~g ,_~ - I ,~
4. Date of lncident: ~'~ ~'~fl~
6. Location of Incident (Be specific): 0~ C,J~
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon wl~ich_¥ou base youLclaim. If a City employee was involved, give the
emoloyee's name.)l"~ ~c/~'Cl~ /qt& I'~'t.~a"r~3 ~
S. What were weather conditions liket '
10. Did police in~¥estigate? (I/f~p, give names of officers.), \ __ ~ .j. ~...
11. Was anyone injured? (If so, give nam~, ~dresses, and extent of injuries).
any damage done to property? (If so, describe property and the extent of damages.
~Sestimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any? --- - ~)_~YT~ "
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.)
16. Why oo you c~aim the uity ol uu q P · ;,
~ i~ ~'~ ~ ~.~¢~e~~~aresultof~hisinciden'?~/~
17. Have yo~ made any Cairn against any
(If yes, give name and address.) ~OP ¢~
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 ,5-~q day of
(Signature)
(print Name)
(Rev. 1/00 & 7/01)