Claim Roling-Danner, Mary Jo (2)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: Mary Jo Roling-Dannar
2. Address: 328 Deerwood Dr., Anamosa, IA 52205
`
3. Telephone Number: 319 462 3322 or 563 580 9948
4. Date of Incident: 14 Jan 05
5. Time of Incident: 12:30 a.m.
6. Location of Incident (Be specific):
Locust & 1st St. NB
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 stopped for seat belt violation and DWI. When emptying out my pockets I stated the keys I had in my pocket were not my car keys.
My car keys were still in my car. I said the Police officials searched my car then locked my doors without taking
my keys out of the ignition. Officer Craiug Samonson's name is on my paperwork. 2 Male Officers and a female Officer
were at the scene. I stated that I thought my keys were probably still locke din my car after we could not
find them when taking inventory of my personal belongings.
8. What were weather conditions like? Very cold, predicated 0 degrees.
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Police Officer that arrested me checked his pockets for my car key.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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?
Fee to unlock my car.
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
15. What amount do you claim from the City of Dubuque?
$32.10
16. Why do you claim the City of Dubuque is responsible?
I told them at the scene the keys they found in my pocket was not my car keys. I said they were still in the car.
While they were searching my car I tried to get their attention (elbow on window of
cop car) to not forget key.
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 14 day of Jan. 2005.
/s/ Mary J. Roling-Dannar
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE,.IOWA -- pou1/'ver
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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.
3. Telephone Number:
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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.) ( T\ I . 'T
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9. Give name and address of any witnesses:
10. Did police investigate? (If so, give ,nar:nes of officers.) __ . __ __ .'
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries). (j'-
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12. Was any damage done to property? (If so, describe property and the extent of damages.
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13. What other damages do you claim, if any?-fo
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14. Have you been compensated for any part or all of your claim by any insurance
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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? T tblJ! ~/VYI rd.. aLl
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17. Have'you made any claim againsfTanyone else for damages as a result of this inci ent? tv
(If yes, give name and address.) J ~ () Mol-
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18. If the answer to Question 17 is yes, have you received any payment from that source, IU-i
and if so, in what amount?
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42813
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