Claim Clark, James K. 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.
1. Name of Claimant: ~"-~$ ~./- ~/~
2. Address: ~ 5'~'~/ ~ f~¢c ~.~+ 7'(~'d.5~
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
/,2-/0 - o ~}
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
emplor~ee's na~me.)_
8. What were weather conditions like?
9. Givenameandaddressofanywitnesses: ~L~ /-- Ci'~.i~, ~5'-":i i O~[~-~c
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 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? ~ O
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?~ ~ ~ ? c~
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 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
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Helping Hands
2644 JFK Road · Dubuque, Iowa 52002
(563) 582-3547
Carol M. & Don Prine Date:
"Insured" Ck. #:
FREE ESTIMATES Cash:
Total Amount Due
~ on this Invoice
Proceed? Call back?
Customer Name ~~z-~ ~
cit/~~ Zip~ Phone 5%~30~ ~
Date C~[ed~/~d/l gateEst: ~ gateHimd Date Completed
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Lawn deanup needed?
Completed? Paid?
Street[~C} /
Waiting period 1 week / 1-2 weeks / 2 weeks Rush? + 25~
Debris Disposal / Time & Fee
Estimated Amount ~t~/O
Sign In Yar~d Hired Today
oo
~. Total Payment Due '~ ¢~Y ~
Ail Services Sedi
Start End Time By Whom Date.
Start End Time. By Whom Date_
Start End Time. By ~nom Date.
Start End Time By Whom Date
Customer Signature Outlets? Hydrant?
How did you hear about us?. Under Estimated? Over Estimated?
Estimates valid for two weeks approximately · Specific day mowing not available · Payment due in 30 days.
Mow estimates are not: to cut lona grass short.
Not responsible for house or underground wires, cables, etc;..
Thank You
NOTES:
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estimate
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Yard Work * Mowin§ * La~ Aeration * Lea~es and Gu~ers * ~ Ro]l~ * Deihatchinfl
Hedge, Tree and Shrub Trimming o Painting · Odd Jobs · Light Hauling
Free Estimates Call (56:3) 582-3547 ° Insured