Claim Jagielski, Lynne
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URT FOR DUBUQUE COUNTY
S DIVISION
LYNNE JAGIELSKI (2/20/39),Zßß~ ~.PR 20 PM 4: 0 I ORIGINAL NOTICE
1890 Key Way Dr. -, -¡: n::;TR¡r'1 Coum
Dubuque, IA 52002 cl~fl"g; iELJ;:-ni It~TY iOWA (Action for Money Judgment)
DubJUU VVV
IN THE lOW AD
Plaintiff,
vs.
No. 01311 SCSCO 5;¿:J,!f3
CITY OF DUBUQUE, IOWA,
Court costs due ¡fthis matter is settled hefore
appearauce or trial. Contact the Clerk for the
amount due.
Defendant.
TO THE ABOVE NAMED DEFENDANT(S): CITY OF DUBUQUE, IOWA
YOU ARE HEREBY NOTIFIED that the Plaintiff(s) demand(s) of you the amount of $5.000.00. (state
briefly the basis for demand): On or about January 17,2004, Plaintiff Lynne Jagielski, while exiting her
vehicle in the Diamond Joe Casino parking lot owned and maintained by the City of Dubuque, Iowa, slipped
and fell on ice in said parking lot, sustaining personal injury damages to her back, neck, hip and hands.
Plaintiff fell as a direct and proximate result of the Defendant's negligence, constituting fault, in the
foIIowing particulars: (I) In failing to maintain the parking lot in a safe condition for patrons such as
Plaintiff; (2) In failing to warn patrons, such as Plaintiff, that the parking lot was icy and unsafe; (3) In
permitting patrons, such as Plaintiff, to traverse its property while it was icy and unsafe; and (4) In failing
to remove snow and ice from its property.
UNLESS YOU APPEAR by completing and filing the attached Appearance and Answer Form with the
Clerk of the District Court, Dubuque County Courthouse, 720 Central Avenue, Dubuque, Iowa 52001 -7063,
within 20 days after service of this Original Notice upon you, Judgment shall be rendered against you upon
Plaintiffs claim together with interest and court costs.
IF YOU DENY THE CLAIM AND APPEAR by filing the attached Appearance and Answer Form within
20 days after service of this original notice upon you, you wiII then receive notification from the Clerk's
office as to the place and time assigned for hearing.
If you require the assistance of auxiliary aids or services to participate in court because of a disability,
immediately call your district ADA coordinator at (563) 589-4448. (If you are hearing impaired, call Relay
Iowa TTY at 1-800-735-2942).
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Attorney for Plaintiff(s) Signature
Danita L. Grant, 000016848
200 Security Building, 151 West 8th Street
Dubuque, Iowa 52001
Phone: (563) 556-401 I
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IN THE IOWA DISTRICT COURT FOR DUBUQUE COUNTY
plaintiff (s) Name:
EIN/PIN*
Plaintiff{s) Name:
EIN/PIN*
VB.
Defendant{s) Name:
Address:
EIN/PIN*
Defendant{s) Name:
Address:
EIN/PIN*
SMALL CLAIMS
APPEARANCE AND ANSWER
OF DEFENDANT
Case No. 01311
SCSCO
DOB**
DOB**
I HEREBY ENTER MY APPEARANCE and
DENY / ADlUT
(ehoose one)
the claim of the Plaintiff(s).
Signature(s) of Defendant(s) or Defendant's(s') Attorney
Attorney's Address
The Court's address is:
Clerk of District Court
Small Claims Division
Dubuque county Courthouse
720 Central Avenue
Dubuque, Iowa 52001-7063
. EIN = EMPLOYER IDENTIFICATION NUMBER (To be furnished, on this APPEARANCE AND ANSWER FORM, by parties who are bnsinesses
or other entities.)
PIN = PERSONAL IDENTIFICATION NUMBER (Will bo furnished by the CIori< of District Conrt for parties who are appearing as individnal, afto'
such parties complete the CONFIDENTIAL INFORMATION FORM.)
.. DOB = DATE OF BIRTH (This infnrmation is reqnested only ftom parties appearing as individnaJs.)
SMALLCIMA.'SWER(4-S-"')
. . J'
IN THE IOWA DISTRICT COURT FOR DUBUQUE COUNTY
Plaintiff/Petitioner,
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,) Case Humber 01311
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"s.
CONFIDENTIAL INFORMATION
FORM
Defendant/Respondent.
Hame
Personal Identification Number
(PIeaIe -, Thi. foan is for tho -- of Sooial- Numbcn
0JIIy. EmpIoy"idcntif_..nnb<n.......-.uy~and
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Plaintiff (s)/ 1.
Petitioner(s)
2.
3.
4.
5.
Defendant (s)/ 1.
Respondent(s)
2.
3.
4.
5.
Other party(ies)
1.
2.
3.
Information supplied by
(print or type)
Signature
Date
CONFINFOPORM(ll.S-99)