Claim Lang, LynnCLAIM 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: Lynn Lang
2. Address: 8429 Burds Rd. Peosta, Iowa 52068
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3. Telephone Number: 556 1609 590 1933
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
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.)
8. What were weather conditions like?
9. Give name and address of any witnesses:
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 describe basis for ascertaining extent of damage.)
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?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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 day of , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
. . Ie (t :;( (9 ~ cc ~ f'I\ V~Jl1
CLAIM AGAINST THE CITY OF DUBUQUE,., IOWA ~
This written report constitutes your claim against the City of Dubuque, Iowa. You sio~m
complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the 9ityClerk 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 CI~lmant:__~~~~
2. Address:~ 1
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3. Telephone Number: 55 Ln - HcC)q 5CO=-l93 ~
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4. Date of Incident: ~ - l f1-(l) IT
5. Time of Incident: lO: ffl OXYI
6. Location of Incident (Be specific): qL/O rrrun ~t-
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
eJD,ployee's name.)
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8. What were weather conditions like? SLLn f\..l..-\
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9. Give name and address of any witnesses: VII{> \\u Co. (\0 \ \
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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 names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of dam'ages.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
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13. What other damages do you claim, if any? ~\ rJ{\Q
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.)
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15. What amount do you claim from the City of Dubuque?$ lCJ \ .?0
16. Why do you claim the City of Dubuque is responsible? ~ 0o..u.c:..<2.. O. ?\Er'P 09: (l
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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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 \ ,5""
day of ,~t^'\\~
, 20.o:L.
~~~
(Signature)
L Y!VAI l.a~
I (Print Na
(Rev. 1/00 & 7/01)
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~103 MCDONALD DR, DUBUQUE, IA 521211213 (563)584-121341
I t'JVO I CE
DATE: 1216--15-1215
T I /VIE: 15: ~S2 : 15
PAGE: 1
\!\.JOICE....P
rOHE# 81-'34
INVOICE#: 8194-31336
)LD TO: LANG, LYNN
8429 BURDS ROAD
PEOST~\ Hi 52121G8
(563)556-161219
UCLE: 2000 FORD TAURUS LX MILEAGE: 800000 TAGll: IA-007 VIN-
!QUE = 95 FRONT = 33 PSI REAR = 33 PSI
~SHIER#_: DWAINE SMITH
Me MFG ITEM NUMBER SUF DESCRIPTION lR an' UNIT$ fEn EXTENDS MISC NOTES
-- --- ------------ --- --------------- ------------------------------ -- ---- -------- ------ -------- --------------------------
08 FS 067865 2156015 FS SUPREME SI BW 94S 76.00 0.00 76.00
NEW OOT#:HYXB5510905
0800 f.160 TIRE DISPOSAl FEE 1 2.99 0.00 2.99
08 PKG TPBAl1 LIFETIME WHEEL BALANCE 1 0.00 0.00 0.00
08BFS 7024341 RUBBER VAlVE STEM 1 2.00 0.00 2.00
08 BFS 7018708 WHEEL BAlANCE - WEIGHTS 1 2.99 0.00 2.99
08 BFL 7001725 WHEEL BAlANCE - LIFETIME 1 10.00 0.00 10.00
08 REC ROTBAl 12152005 RECOMMEND ROTATE & BAlANCE 1 0.00 0.00 0.00
08 BFl 7046930 COURTESY CHECK 1 0.00 0.00 0.00
9<300 1377 MISC SHOP SUPPlIES 1 0.60 0.00 0.60
--------
SUB TOTAl 94.58
SALES TAX f.. 52
INVOICE TOTAl 101. 20
THOD OF PAYMENT AMOUNTS
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