Claim Stockel, Luvern H. 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 N/CT BE PAID·
1. Name of.Claimant~~/.~_/ .~.~~,
2. Address. ~-~,,~'~-'
3. Telephone Number: ,~'~,~-
4. Date of Incident: /~~~
5. Time of Incident: /.
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?
G,..ve name and a dress of any w,tnesses'/
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.~Wha~0ther damages d~b you claim, i~'any?
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
(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?
day of
(Signature)
(Print Name)
, 20 rTxJ ·
(Rev. 1/00 & 7/01)
~°l~'ll ~"'~. K ~' [,,. - AMERICAN CARPET OUTLET ~(~)[~
~lq ~ ~'~ ~''-- Peosta,151001owaRoute5206820 ~C~ 2773[
c,~.~ ~ ~ STAT~ Z'" (563) 556'0242 ~. ~ / /5 /~
'~ ' ~ WORK PHONE CASH
ROOM MFGR.IDISTR. ROLL ~ ~ COLOR & ~ [~ ca sa~ cur
5
6
7
8
s..a~,.s~u~,o.s: ¢¢,'~ ~ C~& PAY FROM SUS-TOTAL
THIS INVOICE
~ ~ ~~' ~ ~ Cash&Oarrypollcyeliminates
a credit department, bookkeep-
ing and collection expenses. SALES T~
that the savings may be
passed along to you by offer- TOTAL .
- ~_~ . ~. ing consistently low prices,
~ FINANCED PURCHASE m~R~ETO~R~DINA~THE~EEME~A~A~EDHE~E~
BA~NCE
DUE
· THE BUYER ACKNOWLEDGES ,I~D AC~PTS THE CONDITIONS OF THIS CONTRACT AND ACKNOWLEDGES RECEIPT CFA COPY OF IT. ,,.¢~2j~j~ DATE COMPLET~~
"TERMS: One-haft down with order. Balance due upon pickup or delivery. / PAID IN FULL:
Thank Tou?
Customer Signature
F
L
O
O
R
I
N
G.