Claim Criss, MaryCLAIM 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: Mary Criss
2. Address: 752 Cottage Place
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3. Telephone Number: 563 557 2647
4. Date of Incident: August of 2002
5. Time of Incident: 12 noon
6. Location of Incident (Be specific):
Hempsted St. near Lowell St.
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.)
Well my son Demond Criss was ride His bike come down the hill, cause on Lowell St was blocked cause road work.
8. What were weather conditions like? Hot outside but not rainy
9. Give name and address of any witnesses:
Well the only witness was Demons & Tony Criss, Timothy McCay
10. Did police investigate? (If so, give names of officers.)
Yes, don't no his name.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Demond Criss was injured cause a car hit his back and made him falling on the ground.
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.)
None was done but to his face back and his bike was beated up on the front tire and plus I feel out a report last year and 2002.
13. What other damages do you claim, if any?
Racism from the Police here cause he did not want to say the Lady was....???
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?
I want the City to pay cause if that Street Lowell was not blocked he won't be hurt
16. Why do you claim the City of Dubuque is responsible?
cause the City was doing road work and to my child could not walk down Lowell St.. They had to us the big hill st.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No cause the office did give any n
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
My son ain't received a dime from so one cause a block (?)
Dated at Dubuque, Iowa this 23 day of March, 2004.
/s/ Mary Criss
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF OUBUQUErlOWA '-:IM~"",
This written report constitutesyöurclaiin;againstthe City of Dubuque, Iowa. You should
complete this form in full and attach any aflditional 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 Counci1 to the appropriate department for investigation.
Once that investigation is completed, a report and recommendation will be submitted to the
City Councn=, YOti wilí be provided with a copy of that report and recommendation.
THE FINAL DECISJONOWALL 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.
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3. Telephone Number:51n'ß. ") 5~'1. jc;),.lP '...r)
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6. Location of Incident (Be specific):
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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 ~R~amount paid.)
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16. Why do you claim the City of Dubuque is responsible? 00 u<:!,-Q. T\A.e Q i ~u.
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17. Have you made any claim against anyone else for damages as a result of this incident?
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Dated at Dubuque,lowa thiS~'3 day otMa rC/h
, 20 ð '-1.
(Rev. 1/00 &~J01)'
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