Claim Leon, JasmineCLAIM 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: Jasmine Leon
2. Address: 2367 1/2 Jackson St.
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3. Telephone Number: (563) 557 3080
4. Date of Incident: 2/13/04
5. Time of Incident: 10:05 Hrs.
6. Location of Incident (Be specific):
Locust at intersection with W. 16th Vehicle was parked.
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.)
(Gansen, Daniel Edward) driving a 2001 Cyclone Fire Truck tried to get out when brook off side mirror and arm handle off my truck, a 96 Explorer
8. What were weather conditions like?
Cold
9. Give name and address of any witnesses:
Parnter and other officers around area, also my sister Ruby which was sitting in the vehicle behind.
10. Did police investigate? (If so, give names of officers.)
Ehlers Badge #22
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No Just my truck
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.)
Yes, Explorer 96 side mirror came off wires and part of mirror remain hanging.
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.)
No
15. What amount do you claim from the City of Dubuque?
To fix the mirror on my vehicle to where the damages that I did not cause would be payed for.
16. Why do you claim the City of Dubuque is responsible?
Because the officer admitted and it was the Fire Truck of Dubuque whom caused these damages.
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 13 day of February, 2004.
/s/ Jasmine Leon
(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.
1. Name of Claimant:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE.
full details upon which you base your claim.
employee's name.)(/~t~r~ ~
8. What were weather conditions like?
(Give
If a City_e~mployee was involved, give the
9. Give nameandaddressofanywitnesses: .~.b ~.h~,~/" ~7¢'~4.r5'
10. Didpolice inves_tig~te? (If so, give names of officers.)
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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 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 ?,9
(Rev. 1/00 & 7/01)
day of '~.~_~ ~p~ ~A
(Signature)
(Print Name)
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