Claim Smothers, BrendaCLAIM 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: Brenda Smothers
2. Address: 794 Clarke Dr. Dubuque IA
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3. Telephone Number: (563) 582 8303
4. Date of Incident: April 10, 2004
5. Time of Incident: 1:20 P.M.
6. Location of Incident (Be specific):
Main Parking Lot outside of the River Museum & Aquarium (was under construction) E of Paddle Wheel
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.)
Walking w/child, there was unlevel land and I stepped on unlevel land causing my ankle to twist and causing me to fall to the Ground with my 15 mo. old daughter. Spraining left ankle
and hurting back.
8. What were weather conditions like?
Clear & Sunny
9. Give name and address of any witnesses:
Lance Smothers (husband) Same as above
10. Did police investigate? (If so, give names of officers.)
No, Hospital Staff called PD - they stated it was private property and was out of their hands.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Brenda Smothers (self) 794 Clarke Dr. Dbq, IA
Received from fall - sprained foot/ankle & sprained lower lumbar (back)
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 day of , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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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.
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6. Location of Incident (Be specific):
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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
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9, Give name and address of any witnessesJ"(l n( (ì ~r'r'IifÑJ~Q\, ¡J,...".I,.,-v,f)
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10. Did police investigate? (If so,
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages,
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13. What other damages do you claim, if any?l-J\D.-
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.)
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16. Why do you claim the City of Dubuque is responSible?~ (J\ I/'\ fX~ \-ü Á,.¡z G ÁÌ,"\
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that source,
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MISSISSIPPI RIVER MUSEUM
- & AQŒ\RIUM -
Port Of Dubuque
350 East3rd street
Di.Jbuyue;IA 52001
Phone: (563) 557c954£ ., -
Date: ,04/10/2004 Ticket 7009ê -
Time: 13:38:4¡" Clerk: 8441
8.75
8.75
Total:
- Tax:
Grand Total:
Tender:
Change:-
20.00
2.50
Cash:
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