Claim by Rose SchaepeCC
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA Aaa,e,t5 l
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 13th 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 kost. Sail a f
2. Address:
3. Telephone Number 5-f3 5'3 -
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4. Date of Incident: Otohir (, 2.0 I 1
5. Time of Incident: / 2 ' Sn Pm
6. Location of Incident (Be specific):
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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.) _
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8. What were weather conditions like?
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9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
The orange "X" indicates the area where the accident occurred.
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