Claim, Meyer, Ricky
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA -j'.(w.. {<-.
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This written report constitutes your claim against the City of Dubuque, Iowa.
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 St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
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;- A"f~ //'76-?/ C /2
2. Address: /.3 c; y {7Ac.A::-~:/V 5- r
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3. Telephone Number $"""(03-<r'95""- ~ &3 0
4. Date of Incident:~~ /5; .:2a~
5. Time of Incident: /03CJ [;42.
6. Location of Incident ,(Be ~e~'c): , .-. . ./- ./
/;;;~~~~/ MLP''''/D,LAdq~"H.> $/. ~/.
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 namE7) .
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8. What were weather CQ?iOnS like?
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9. Give name and address of any witnesses:
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10. Did police jn....~stigate? (If s~ive names of officers.)
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11. W~~ anyone injured?
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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.) .
13. What ot.h.er dam~ do you claim, if any? . J
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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.)
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15. What amount do you claim from the City of Dubuqu ? ~
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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.~t'
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated this / /? day of c -;;;~
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TO: City of Dubuque
July 17,2006
From: Ricky Meyer
1364 Jackson St.
Dubuque, iowa 52001
PH# 563-495-6630
On July 15,2006 at approx. 10:30 a.m. I was walking in the alley going
north bound between Jackson St. and Washington St. in the fourteen
hundred block. In the alley there is a pothole in which caused me to trip. I
substained injuries to the left shoulder and the left wrist. I went to the
Finley hospital and was treated for a sprained shoulder and a five and a
half em. laceration on the left wrist. A police accident report was filled out,
report # is -06-31615. Please find enclosed a copy of the pictures of the
pothole.
The pothole measurements are 34in. in lenght by 21in. in width by approx.
3 in. in depth. This is located in the alley beside an apartment complex
which I beleive the address is 244 east 14th. St.
I beleive that the city of Dubuque is responsible and is negligant for the
cause of my injuries. I'am requesting that all and final medical bills be paid,
Also for pain and suffering. I beleive that a negotioable amount of
$5500.00 would close this claim agianst the city of Dubuque.
SINCERELY,
RICKY MEYER
CC:
CITY OF DUBUQUE
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