Claim Country Springs Condo Ass
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CLAIM AGAINST THE CITY OF DUBUQUE;'IOWA '.-' bk,vt'Lj. rlf\fl.
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This written report constitutes your claim against the City of Dubuque, Iowa. You IsJould
complete this form in full and attach any additional information that supports your claim.
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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: (crt/A/fA'-! ()PÞI,,'/\/&,.C; C:P/YOðh'oM.<'t'W/¡,I":p'? A<sSoc-,..
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2. Address: )J7/1 !?4u/tbf;VÀ LJR ,~I ,¡](/fly VIYr/~¡4, J:'ç}O¿;7 /
3. Telephone Number: ,1'% l- - J c" ý/l
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4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific): c;. {/tflJ (ì /1Jp. MA I/., BrvU::S ;/V FRðN7 (J/="
,/ J 9< r ;9/1&4 fJ¡;'/ý/J Of(, ~ UNITS' -# r; ô
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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
emp~yee'sn?m~.) /V.A-~¡;;O¡::{)¡;¡V;¡:'¡;¡f,';TC4;H 1J4J..,J//VG- ~ '
CIIY ./\4,/I//ßus {JI(,V1YJ. WAS /ìfèÁrUF¡:(IÁ/("- -LJ /(ID¡;:/J. /oN/,<\ Nð/,);}Æ
CJOJ'/-I "rcð¡:J/VIANl I tI/H$Æ/' OR/V.J!R PU/,t..£.'O /0 CC//J./] //7£ Â4/lC£
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8. What were weather conditions like? ('.J, F~ Æ<, ~ S 1 {A/..yy (.fC..:? -¡'If)! If. )
9. Give name and address of any witnesses: /JI( I r/Jlf.< /~¡:'¡jIl';("(E(1 /)EÁNAfJ!- /(lJl?fJ/yy/V
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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).
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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.)
DAMI/.(;<i: Ît1(j; !?uT{,J7J... ÎY¡Jrr-/vj.:tJ/t..r3~)(~Y' 1f<p(ß},! !}i,a/V¡;- r.{/,//¥
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Tn ßE I(FP/..7J. eE() 4 S'AP To G ()/y'TfN uç /'1.'"-1:1:' ()¡:: 1. j VI:£l¡! ~ CcJ/Í/fPL RT¿;,(J
13. What other damages do you claim, if any? C/ð5/ t5ç RJ? fJA ¡Xl. , ;ÑP L I'J/{,.'N/r-
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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 and amount paid.)
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15. What amount do you claim from the City of Dubuque? xl7~ f J' 4<'
16. Why do you claim the City of Dubuque is responsible? Á1 I 'tV -'81'/:5 ur /l ~
,PI< &Pfil{11/ t9,F C/,'TV""Hl!) ¡];:?/YE t::2 W.4 4;' (e'y"o~tJ..... C; Ty ,J'ClPFtJ. \-!/J/,°Á/ J
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,
and if so, in what amount?
Dated at Dubuque, Iowa this \ r::z;!i day of
lnr lia
,JULV
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(Signature) .
ÐaJ~ ~ rl 2 ~., bc:h
(Print Name)
, 20Q$(.
(Rev. 1/00 & 7/01)
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LOWE'S
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To /A 10 - 72.,35<
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DUBUQUE. IA
(563) 5B8-8D08
-SALE-
SALES I: SDI17JAl 751718 07-01-04
,-.73 &,
950 lX6X6 TOP CHOICE 2.44
175662 STANDARD US RURAL 32.88
3 8 10.96
64401 DRYNALL SCR 6XH 2.27
30638 2" REFLECTIVE NYL 0.33
31127 2" REFLECTIVE MYL 0.99
38 0.33
30706 2" REFLECTIVE NYL 0.33
30983 2" REFLECTIVE MYL 0.33
SUBTOTAL: 39.57
TAX 32165: 2.77
INVOICE 45345 TOTAL: 42.34
/0,015 H/?/
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R 13 PA i ~ PE r<;::tJ~éE ()
ß1 (/ J, k f?/} AxE f!(
ßy
8ALANCE DUE:
42.34
VISA:
42.34
A 7Thé/l./?IJ / 77'~-/\/í/z£/J
8/1-. Á.. ßR. /--1A- TkR/A L
VISA XXXXXXXXXXXX2153
AMOUNT: 42.34
045916
-m______--------------------_o_---
0117 TERNINAL: 45 07101/04 17:49:55
THANK YOU PAUL J KRAMER
FOR SHOPPING LOWE'S
RECEIPT REQUIRED FOR CASH REFUND.
CHECK PURCHASE REFUMDS REQUIRE
15 DAY WAIT PERIOD FOR CASH BACK.
STORE MaR: NARK LAWLOR