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Claim by Mark JenningsCLAIM AGAINST THE CITY OF DUBUQUE, IOWA 0 This written report constitutes your claim against the City of Dubuque, Iowa. You )M'' 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 Attorney's 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: ,M 4 1/( J EMU f & 6 S 2. Address: ! z. j 4 C.. S on/ 3. Telephone Number 5( - 8 fi -- o ) S C� 4. Date of Incident: - I 5. Time of Incident: 973 6. Location of Incident QE3e specifi ): ` 1 ,. ? t) � ) A c::ris CAN 7. Describe the 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.) Pie G, b r car c 1. ; 'C K e 0 -4'. `-��(' ' , c . ,r e - OP- vYLi VaYti t o 4) is 1. nnc. 8. What were weather conditions like? (V R-c-5T - 9. Give name and address of any witnesses: Z E' 16r- ir"vAS 53 2-5 LL.4s5 LA. Xj' ' PC7WtLL Awl 41 )4L S a 3 ct +k ►cjct. - Dv _rot.. 4 10. Did police investigate? (If so, give names of officers.) 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). n0 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 e ent of dam Age.) i o ✓G2.•in (Q C (JZ 2. 1 b i y (L,.\± j c.l ,5 ),p-ci / i4 c d s wt.4) )12 - () cL 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? 16. Why do you claim the City of Dubuque is responsible? I -d1Q._ a - Y - P∎ c.' %e �1 C) OA C , f W 17. Have you made any claim against anyone else for damages as a this incident? (If yes, give name and address.) YL© 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated this day of S LA E , 20 \ ` . (Signature) (Print Name) Y1 t.IN7 5 result of ( tsoiq 4r b(e) Fri C) m S 1 ' 0