Claim Sheldon, Jennifer CLAIM AGAINST THE CITY OF DUBUQUE,s. 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:,..~.Y~T'~F_~
2. Address: ~ ~c.~c::{l~
3. Telephone Number:
4. Date of Incident: ~ c~'\ \
s. Time of Incide,t:
6. Location of Incident (Be specific):
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.)
8. What were weather conditions like? .~.\ O
9. Give name and address of any witnesses:
1~. Did police investigate? (If give names
|~ ~. ~ ~f")C'I~ ~ so, 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 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 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?
16. Why do you claim the City of DubUque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give ~.~%~.~add ross.)
J
18. If the answer to Question 17 is yes, have you received any payment from that source,
and ifv~o~in what amount?
Dated at Dubuque, Iowa this
(Rev. 1/00 & 7/01)
DPD~O~-01-97~-~' DUBUQUE POLICE DEPARTMENT PROPERTY IN CUSTODY
1. Dote 2. Case No. ~, 3. Cas .Date ,
6. Purpose J'or Whish Obtained
, / Complaint Piled/
Evidence ~_~-/ Safekeeping Found Pending Other
7. Owner or Persons Having an Interest in the Property and o Right to File a Claim (with address)
NAME DC)~: ADDRESS PHONE
8. Items I HAVE PLACED THIS PROPERTY IN A PLACE OF SAFEKEEPING FOR TRANSMITTAL TO THE DEPARTMENT PROPERTY
L~st OFFICER. I HAVE GIVEN A COPY OF THIS FORM TO AS A RECEIPT·
A Thru Z Quantity DESCRIPTION OF ARTICLE - LOCATION WHERE FOUND
~ ~ r ~
: 4278
12. Seized Property Order Requeste~
Date
S.P. or S.W. Order No.
MARK ALL ITEMS FOR FUTURE IDENTIFICATION CUSTODY CHAIN ON REVERSE SIDE
DPD 08-01-97 DUBUQUE POLICE DEPARTMENT PROPERTY IN CUSTODY
4. Per'son Property W~$ Take;n From or Received From
I
2. CaseNo. .. 3. CaseDate
Location Where Obtained. Be Specific - Address - Vehicl,e with Lic. No. - Person '
6. Purpose f or Which/Obtained
~ Complaint Filed/
Evidence ~ Safekeeping Found Pending Other
?. Owner or Persons Having an Interest in the Property and a Right to File a Claim (with address)
HAME DOB: ADDRESS PHONE
8. Items I HAVE PLACED THIS PROPERTY IN A PLACE OF SAFEKEEPING FOR TRANSMITTAL TO THE DEPARTMENT PROPERTY
List OFFICER. I HAVE GIVEN A COPY OF THIS FORM TO AS A RECEIPT.
A Thru Z Quantity DESCRIPTION OF ARTICLE - LOCATION WHERE FOUND
' i
~'~ '.'- , ~; ..... e ~ ,- _ .
9. Date, , ,,.Officer(s) Name ~yped or Printed) Baage No. ~ ~ Officer(s) Signature 10. Receiving Locker No.
11. Ev/denceR.mStorogeNo. , 4280 -9~
12. SeiZedDate Property Order Requested S.P. or
S.W. Order No.
MARK ALL ITEMS FOR FUTURE IDENTIFICATION CUSTODY CHAIN ON REVERSE SIDE
DPD 08-01-g7 DUBUQUE POLICE DEPARTMENT
1. Date
PROPERTY IN CUSTODY
3. Case Dote
~ ~: ~:,~ Phone---~
Case No.
Address
4. Person P~:oper ty ~T~'~raken From or Received From
5. Location Where Obimned. Be Specd~c - Address - Veh cie w th L c. No. - Person
6. Purpose for Which Obtained Complolnt Filed/
Evidence Safekeeping Found Pending Other
7. Owner or Persons Having an Interest in the Property and o Right to File a Claim (with address)
N~ME DOB: ADDRESS PHONE
8. Items I HAVE PLACED THIS PROPERTY tN A PLACE OF SAFEKEEPING FOR TRANSMITTAL TO THE DEPARTMENT PROPERTY
List OFFICER. I HAVE GIVEN A COPY OF THIS FORM TO AS A RECEIPT.
A Thru Z Quantity DESCRIPTION OF ARTICLE - LOCATION WHERE FOUND
9. Date Officer(s) Name (~yped or Printed) Badge No. ] Officer(s) Signature t0. Receiving Locker No.
1 I. Evidence Room Storage No.
02¢0 -00:
12. Seizedoate Property Order Requested S.P. or S.W, Order No.
MARK ALL ITEMS FOR FUTURE IDENTIFICATION CUSTODY CHAIN ON REVERSE SIDE
DPD 08-01-97 DUBUQUE POLICE DEPARTMENT
PROPERTY IN CUSTODY
4. Person Property Was Taken From or Received From
·
5. t~ofion Where ~b~o~n~.
6. Purpose far.Which Obtained
Complaint Piled/
Pending
Other
Owner or Persons Having an Interest n the Property and o Right to Fle a Claim (w~th address)
NAME DOB: ADDRESS
PHONE
8, Items I HAVE PLACED THIS PROPERTY IN A PLACE OF SAFEKEEPIN~ TRANSMITTAL TO THE DEPARTMENT PROPERTY
List OFFICER, I HAVE GIVEN A COPY OF THIS FORM TO,~?~¥~ 7 AS A RECEIPT.
A Thru Z Quantity DESCRIPTION OF ARTICLE - LOCATION WHERE FOUND
I1. Evidence R~m Storage No. 2363 -00:
Seized Property Order Requested
S.P. or S.W. Order No.
Date
MARK ALL ITEMS FOR FUTURE IDENTIFICATION CUSTODY CHAIN ON REVERSE SIDE
DPD 08-01-~7 DUBUQUE POLICE DEPARTMENT PROPERTY IN CUSTODY
1. Oate
2, Case No.
3. Case Date
Name II)OB:
Phone
5. Location Where Obtained. Be Specific - Address - Vehicle with Lic. No. - Person
6. Purpose for WhichObtoined
~- Evidence _~-~
Safekeeping Found Pending Other
?: ~w~er ~r~r~e ~sons Having an I ~ Yeres tan. th e~P.r~pm'ty~ o Right to File a Claim (with address)
NAME DOB: ADDRESS
PHONE
8. Items t HAVE PLACED THIS PROPERTY IN A PLACE OF SAFEKEEPING FOR TRANSMITTAL TO THE DEPARTMENT PROPERTY
List OFFICER. I HAVE GIVEN A COPY OF THIS FORM TO , F/,~ AS A RECEIPT.
A Thru Z Quantity DESCRIPTION OF ARTICLE - LOCATION WHERE FOUND
0771 -00
12. Seized Property Order Requested
S.P. or S.W. Order NO.
MARK ALL ITEMS FOR FUTURE IDENTIFICATION CUSTODY CHAIN ON REVERSE SIDE