Claim by Zac & Amy Scherrman(Ae,- ✓ ✓7i 7
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. 13 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: zGIL `t' Rmi Sc-he l - mo o r\
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2. Address: 8 05 5uilil fzundvittu Dubu �.,�Q , 'L4 5O3
3. Telephone Number: 563 - 543 - 76 80 of 56 3 - 54 3- 4 7a
4. Date of Incident: 1 t � L q ( l 0
5. Time of Incident: b2'tu1Qk4 kw 6 t S 0.((1
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
6. Location of Incident (Be specific): 805 55 Grd ntkv a 1 1 i (1Q
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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
employee's name.)
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hat were weather conditions like? 1, Sc.1n 1 z �e �►.�m�e�n� � fir` b lad, �Nna�
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9. Give name and address of any witnesses: nON-
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
zo:6leoz/ any damage done to property? (If so, describe property and the extent of z3� z
amages. Attach estimates of damages or describe basis for ascertaining extent of
damage.)
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13. What other damages do you claim, if any? Nc7dl�
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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1 What amount do you clai fro the City of Dubuque?
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16. do yo claim the City of Dubuque responsible? , - i & GL vertu S
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17. Have you made any ' laim aga 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 D Iowa this
( -day of ' Fib( W.V , 20 1! .
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(Signature)
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