Claim, Egan, Karen
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CLAIM AGAINST THE CITY OF DUBUQUE;IOWA . c ' ~~ /
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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 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 Y.OUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of ClaimaQJ~'v\, ~--f\-- ~ .
2. Address: Cj d. r Jo,eto "-~
3. Telephone Number: 54 3-QG4? I '.
4, Date oflncldem, Q,j) ''''Ii wl>s Gbp ~'J~~ I ! Os::) Q If
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5. Time of Incident:
6. Location of Incident (Be specific): q d-
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.) Oevw ~cD.
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S, Whnt..... weath., con on, like? S,v,\"t:J . '" · . C,,' ,
9. Give name and address of any witnesses: t-J,,\ ~ L ~l{,i~'
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10. Did police investigate? (If so, give names of officers.) (l,:>
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 damages. -
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? N U
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? ~ ~---':)iJR.o U y\tJ D
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o you claim the City of Dubuque is responsible?
17. ave you made any m 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 _No.)
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day of 19-0-- ' 201:2.)
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(Rev. 1/00 & 7/01)
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Use Your \~~~\ 1%
BIG CARD'Frr.,''''''''REBA TE
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5300 DOdge Street
Dubuque. IA 52003
111111111111111I1 II 1111111111111111111111111
Sale Transaction
3' X 4' MARATHON MAT
7031467
3' X 4' MARATHON MAT
7031467
34GAL TRASH CAN W/ W
6483003
6,97
6.97
TOTAL
TAX AT 7%
TOT AL SALE
CHECK # 1149
924232
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30.43
2.13
32.56
32.56
TOTAL NUMBER Of ITEMS . 3
THANK YOU, YOUR CASHIER, PATRICK
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18772 07 5741 11/06/05 11:24AM 3057
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