Claim Williams, Nancy L.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: Nancy L. Williams
2. Address: 125 W. 9th St., Apt. 309
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3. Telephone Number: 563 582 1160
4. Date of Incident: June 15, 2004
5. Time of Incident: 6:30 A.M.
6. Location of Incident (Be specific): 9th Iowa Coming across to Henry Stout Apartments.
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.)
I was walking home from the gas station on 8th & Central and stepped ofrf curb and fell. I don't know if I tripped on the street or not.
8. What were weather conditions like?
9. Give name and address of any witnesses:
None that I know of... I was very early, the girls at Gas Station will remember me being there.
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
I fell on my hand and went to Hospital. It is not broke but badly bruised and I am wearing a splint on my right hand.
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.)
No
13. What other damages do you claim, if any? None
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.)
I fell on a hole between St. and sidewalk and broke my ankle. They paid my hospital bills.
15. What amount do you claim from the City of Dubuque?
I don't know I just wanted the street checked so no one else falls.
16. Why do you claim the City of Dubuque is responsible?
I just want to know if it is the street so it can be fixed.
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?
No
Dated at Dubuque, Iowa this 17th day of June, 2004. .
/s/ Nancy L. Williams
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUEj'IOWA .~. .. .-
This written report constitutes your claim against the City of Dubuque, 10W?:w~ou Sh!:;:;ø~
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: N f1 No. '/ ¿..". IN ¡ i.¿ / ,,¿¡ /'v7 ::;;
2. Address: /.2~ W 'tí]¡ ò'1 AfT 30-9
3. Telephone Number: ..5- t,,:3 5" ¡r- ':;! I / ~ 0
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4. Dateoflricident: JuNE /S-~~ODLr
5. Time of Incident: ¿ ,/30 11 M.
6. Location of Incident (Be specific): 7 I/) ,:rO'v{) A
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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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8. What were weather conditions like?
9. Give name and address of any witnesses: /]10 IV Ii TJ¡ a.., r 7- /('6 W 6 p
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10. Did police investigate? (If so, give names of officers.)
No
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.
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? Iv 0 1\Itç-
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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15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
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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.) . N CJ
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount? N cJ
Dated at Dubuque, Iowa this 6-J 7- c7°?-aay of
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(Rev. 1/00 & 7/01)
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