Claim, Boelk, Robert D
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This written report constitutes your claim against the City of Dubuque, Iowa. Y~hO
complete this form in full and attach any additional information that supports your claim.
.,.'
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
. .
.
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: Rob e R -j- D h? 0 e. 1 K
2. Address: ;;>. S- r;, (, G I ~Y1 v' (> uJ C In. <- 1""'-
3. Telephone Number: S-~ a S" s 7 - 9/ (., c..
4. Date of Incident: Thu 17 , J1.1l"1l1c l., . <9 . ;{ () 0 b
5. Time of Incident: ~: L.f ,-S- ;q m , f/ It Un s: )
6. Location of Incident (Be specific): B f7 S (> In .. " f. L;q u.. j 17. 'I R cD 0 I,.,
, / /
.5 -f Dh e !? 6) 0 Wl R e C (l..e ",-i,,'Jtv 17 co'.... .
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.)
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<JJu'+ 0'-( ....."'. oDD"" 1<'...'1>/,1"............) off l.vl4 "'<0.. cjQ.irccl
MIR' f?<>ci..... ,.q"d 0........,"1 <; t.,.. LI(,/P' . ~...d 5'..f t , ",...J f.'"".....J :l. s +,.",,,-;-
h1.~nJ {-4L.tlle:> -lPJtl, .I;1~ (.*'~tlcc: c:_ j.'.:J.\o't.. --j"",c:y ...."11' \".(&5~f;J ,r~v..:>("rZ. "........._:>
8. V'I~~eather'fondltlons like? . '" ..., ~ I, ~t ,,1' '
t.9.~__C_146t-J j-loqJ J7quv ;J.....,-l-~ k+ /3,-/ 1101...,), .
9. Give name and address of any witnesses: /"'1 's '" 8 t ",,+ C i I- \J 12 loA ploY e <. > '\
. (Tcjq\rw<. jw'.....J41;t,d. Si4u.J t.,UWA--I (1Joq.~vCJ,v-J
JOhl1 /-fl4f\!f>Cnll5'3'1 Lc:.u,..JI S-i, 011Q(,1~ 13",../(::,2.5"'" <:;;t....",..v.o.c"
f11I?, R"'ofel'Z.- .. 5'<'n.u"", 1M,q~,- Po, 80)1 /'"31"2-, iJ'-''.,'-'~u''', ::Lq
10. Did police investigate? (If so, give names of officers.)
/"!0
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
/YD
12. Was any damage done to property? (If so, describe property and the extenl'of damages.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
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/?o~evt- lSoeJ1(- .5u~j(''''J LI 'P w..iwo,.... - '1h/(s, <::'O.OD
John HlQiYS()/y /, Ir ,,/ ~ hn- ~S-, 00
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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.)
No
15. What amount do you claim 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 incident?
(If yes, give name and address.)
No
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 'ru -es day of h114 n <-L,
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(Signature)
Ro Ioev -+ D 736"," I b;,.,
(Print Name)
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(Rev. 1/00 & 7/01)
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