Claim by Charles SulcerCLAIM AGAINST THE CITY OF DUBUQUE, IOWA
,ee.
Z4,
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: ' 'g%( / /f ///f O / /S. crev
2. Address: /2 //4/ Lgo) (J' /Il y /9l/4' ` ,W 1.1-d" .12i10-7
3. Telephone Number: 4v5-....2v7 --s(o#,e2` —
4. Date of Incident: ,90c7/24/
5. Time of Incident:
d/ 3 fg 1
6. Location of Incident (Be specific): ££/4s-4 ,2M/ -7 --W*I )1/ 2
/115114 fea Me/6
7. DESCRIBE ACCIDENT OR OCCURRENCE THA AUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City e
employee's name.) O 1qw, ag ,Q/ a74
(-5-74:1 c/r /
�'/a m
8. What were weather conditions like? C 2
9. Give name and address of an witnesses:
"�ployee was involved, give the
e
/ iiiE. ' L.�0
fCQ ('gi4 L
'i� / ICo/R CS3lf/ --% /-.474,57
-Fd %re(tbir GCS . r 3r , C'64,17
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
12. Was any damage done to property? (If so, describe property and the extent of damages.
Attach estimates of damages or • -scribe basis for ascertaining extent of damage.)
/0,471I'M 011
at other damages do you claim, if any?
P €(74a b/b ("/-
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.)
fir
15 What amount do, you claim from t e City of Dubuque J
ilt ,� z& �r.a (l/lC ,�fzC ($
16. Why dq you claim the Cityaqf Dubuque is responsible? Au
17. Have you made any claim against anyone else for damages as a res of this incident?
(If yes, give name and address.)
A I
18. If the answer to Question 17 is yes ave you received any payment from that source,
and if so, in what amount? A/
Dated at D. uque, Iowa this 30 day of
(Signature)
%I
(Rev. 1/00 & 7/01)
ZD
Tracey L. Stecklein
Paralegal
Suite 330, Harbor View Place
300 Main Street
Dubuque, Iowa 52001 -6944
(563) 583 -4113 office
(563) 583-1040 fax
tsteckle @cityofdubuque.org
Charles Sulcer
chsulcer@us.ibm.com
RE: Claim Against the City of Dubuque
Dear Mr. Sulcer:
Dubuque
rur
2007
Masterpiece on the Mississippi
August 29, 2011
If you wish to file a claim against the City of Dubuque, we-would request that you complete
the attached claim form and return it to the City Clerk's Office at the following address:
Kevin Firnstahl, Acting City Clerk
City Hall — City Clerk's Office
50 West 13th Street
Dubuque, IA 52001
Once the claim has been stamped in by the City Clerk, it will be forwarded to the City
Attorney's Office for investigation.
Very sincerely,
Tracey St'ecklein
Paralegal
Enclosure
-I
v