Claim by Danielle BastenCLAIM 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 West 13 St., Dubuque, IA 52001. It will then be referred to
the appropriate department for investigation and to the City Attorneys Office. 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:
2. Address:
3. Telephone Number:
5. Time of Incident:
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4. Date of Incident: ()c / (3' fir
6. Location of Incident (Be specific): Di-. [- -r'Tf
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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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7. Describe the accident or occurrence that caused ih}dry 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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9. Give name and address of any witnesses: `41 ' t i"
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?
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?
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16. Why do you claim the City of Dubuque is responsible? L-+' S(14144 if (/1 S
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st anyone else for damages as a result of this incident? (If yes, give name and
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
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