Claim Myers, Susancc: MVM
Barry
Eng. Dept
Jane Smith
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: Susan Myers
2. Address: 506 Lowell St.
3. Telephone Number: 588-1167
4. Date of Incident: August 26, 2004
5. Time of Incident: early afternoon around 1:30 - 2:00
6. Location of Incident (Be specific): At other end of 500 block of Lowell St as where I live. Same side of street as
my residence.
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 with my neighbor's 10 year old son who had my dog on the leash. I was advising him to
be careful with my black lab so he wouldn't get hurt. I stepped into a hole in the sidewalk, my right ankle gave out
and I landed on my left knee onto sidewalk and knee tore open.
8. What were weather conditions like? Sunny
9. Give name and address of any witnesses: Darrin Hanson 534 Lowell St.
10. Did police investigate? (If so, give names of , officers.) They took a statement from me in Finley's ER.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Myself. Tore knee open to the bone
which required 17 stitches to close. Went to ER three times. Once for stitches, second for pain which wasn't eased
with medication and third time for removal of stitches.
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.) None
13. What other damages do you claim, if any? I find myself still at this date having tenderness and pain in
my left knee. Have not followed up with a doctor since I don't have insurance.
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.) No, I don't have insurance.
15. What amount do you claim from the City of Dubuque? $2500
16. Why do you claim the City of Dubuque is responsible? It is the city's property. If the sidewalk was in good
repair, I wouldn't have falled and been injured.
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?
Dated at Dubuque, Iowa this 19th day of October, 2004.
/s/ Susan Myers
(Rev. 1/00 & 7/01)