Claim Curiel, DebraCLAIM 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: Debra Curiel
2. Address: 1105 Walnut, Apt. #1
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3. Telephone Number: 563 582 1735
4. Date of Incident: 9/30/06
5. Time of Incident: 8-9
6. Location of Incident (Be specific): 656 West 11th Street (on grass near curb
on thecan(Blue) with cement in it.
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.)
Was showing the police where some kids lived and when I walked on thelawn I steppedon the can andcut my foot.
Not sure who is at falt.
8. What were weather conditions like?
Good night and every dark
9. Give name and address of any witnesses:
Dubuque Police Officer - Harden Andrew 770 Iowa
10. Did police investigate? (If so, give names of officers.)
same as above.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Debra Curiel
1105 Walnut, Apt. #1
Cut open big bottom of big toe
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.)
No damage to property
13. What other damages do you claim, if any?
Cut open my toe and had to take ambience up to Finley Hospital - get stitches in my toe
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.)
Title 19 but was only (pay doctor bill) (not ambulance) and hospital bill)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
Not sure if City or owner of property is at fault. - need to find out.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) same as above
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Not yet
Dated at Dubuque, Iowa this 4th day of October, 2006.
/s/ Debra Curiel
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA Mt~'
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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 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 Wil~1I not be paid. , J
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4. Date of Incident: q / ~ 0 I <::7 &,
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5. Time of Incident: <{ - '1
6. Location of Incident (Be specific): ~. . .' ....'... .' i
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'1. 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?
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9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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\t1as anyone injured? (If so, gi'"ne 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? ~ ~
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14. Have you been compensated for any part QJ 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?
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16. Why do you claim the City of Dubuque is .res
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 wy,t amount?
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Dated thi~ !{)/~Jt'J.day of ~ OC"J.
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