Claim by Archie Ralston Jr.Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
MEMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: March 6, 2012
RE: Claim Against the City of Dubuque by Archie Ralston
Claimant Date of Claim Date of Loss Nature of Claim
Archie Ralston 3/05/12 12/31/11 Personal Injury
This is a claim in which claimant alleges that he was injured during an altercation with
police.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
Mark Da!sing, Chief of Police
Archie Ralston
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944
TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org
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 West 13t" St.,
Dubuque, IA 52001. It will then be referred to the appropriate departmertf6t
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: / /rc.141
2. Address: , 1
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3. Telephone Number )3' 3 nd S 3 -5-67 47" 3 73 1-%
4. Date of Incident: 1") Vec r 4 c) )
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5. Time of Incident:
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?
9. G.ve name and address of any litnesses:
10. Did police investigate? (If so, give names of officers.),
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11. Was anyone inju
d? (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 damages. Attach estimates of damages or describe basis for ascertaining
exteat of damage.)
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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.)
1,.What amount do you_ ,
qlaim from the City of Dubuque?
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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 inci tit? (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?
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Dated this,, ,
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(Signature)
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