Dorothea Tschiggfrie Claim
CLAIM AGAINST THE CITY OF
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DUBUQUE .
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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
West 13th Street, Dubuque, Iowa 52001-4864. 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: \J)6Ytl'hleCL
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2.
Address: ~ '18 t.J t1 />1 n ~ t
Telephone Number: ,-')'~;2- ,s-S-g 0
Date of Incident: 9 - Cl () -0 0
Time of Incident: / tJ, ()O!;; /0: ,3 ()
3.
4.
5.
6.
Location of incident. (Be specific)
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7 . DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE.
(Give full details upon which you base your cla~. If a City
employee was involved, give the, employee's name.)
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8. What were weather conditions like? ':YI""~ ~ ~
9. Give name and address of any witnesses. ~..? ~ _ fO:/. c..2>rIi.
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10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give name, address and extent of
injuries.)
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12. Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
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13, What other damages do you c1aim. if any? -r~lb I rAt d:L c Ii)
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14. Have you been compensated any part or all of your claim by '-Brc,a1.
any insurance company? (If so, gi ve name and address of b '\ ~-
insurance company and amount paid.) If ()
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15. What amount do you claim from the City of Dubuque?
:P 977. ?a.
16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a
result of this incident? 'nO
If yes, give name and address:
18. If the answer to Question 17 is yes, ha~e you received any
payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa, this
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(Print Name) 0 I
8":\ tJd az IJO 00
(Revised January, 2000)
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STEVE'S ACE HARDWARE
1670 ,J"FK ROAD
(319) 556-8030
7011430
SEED GRASS FALL "IX
2 @ 5.490
SUBTOTAL
TAX01
TOTAL
CASH
CHANGE
10.98
10.98
.66
11.64
20.00
8.36
THANK YOU FOR SHOPPING AT STEVE'S ACE I I
KH 10/01/00 12:05P" 801084610 08
BIG CARD
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STEVE~S ACE HARDWARE
1670 JFK ROAD
(319) 556-8030
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7011430 SEED GRASS FALL MIX 5.49
SUBTOTAL
TAX01
TOTAL
CASH
CHANGE
5.49
.33
5.82
10.00
4.18
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.,
THANK YOU FOR SHOPPING AT STEVE'S ACE! I
KI'lH 10/05/00 1:0H'1'l 11010867&2 0'3
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STEVE~S ACE HARDWARE
1670 JFK ROAD
(319) 556-8030
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7011430
SEED GRASS fALL "IX
SUBTOTAL
TAX01
TOTAL
CASH
CHANGE
5.4'3
5.4'3
.33
5.82
20.00
14.18
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THANK YOU FOR SHOPPING AT STEVE'S ACE~ I
KH 0'3/30/00 10:12AI'l 110108402& 0'3
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762185
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Customer's
Order No.
'27 S 1 Date Ie - 5 - c c.
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SOLD BY CASH C.O,D, CHARGE ON ACCT. MDSE. RETD, PAID OUT
QUAN. DESCRIPTION PRICE AMOUNT
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ALL claIms and returned goods MUST be accompamed by thIS bill,
Rec'd By