Claim by Gansen ExcavatingFROM GANSEN EXCAVATING FAX N0. 3195568044 Jun. 07 2//007 08: 17AM ~JP/2/~~//~//
CLAM AgA~NST THE CITY OF DUBUgU~, IOWA /~~2 4
'1'hs wrlttsn to rt ~~ _ ~~G!~~
Po constitute~r'your claim against the Cny of Duburiue, ivwa You should
complQta thla form in lull and a~aoh any additional lnformaflor~ that supportts your claim.
The Ctelon must be lilad with thr City Cisrk at Clty Hafi, b0 W.13'" St,~.Dubuque, IA ;12fl01.
It wilt then be retat7'~d by the City. Council to the appropriate department for farvest
Onoe first in'vestigatlan is oompleted, a report and reoolrtmet~datlon will lye subm the
City Cougoil. You will ~ provided with a copy of that r+t+pork and rccammendetlon.,
THE FINAL DSClSION ON ALL CLAIM3 !s MADE i3Y tliE CITY COUNCIL. NO EMPLOYEk
rJF THE CITY C1F DUbUgUE HAS 'fHE AUTHCRi'i'Y TO MAKE ANY R~PRRSBNTATiON TO
'YOU AS TO WHETHER YOUR CI.AiM ~AIlLL OA 11IfiU. NOT 8E pAID.
i. Name of Claimant: L
2. Address• ~ '
3. Telephone Nyrn~; 5
4. Data df lneidsrlt:~_
6. Looetlan di incident (~
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7. DeSC~tiBL ACCIDENT OR~ OCCURRENCE THAT CalfSlaD INJURY OR DAIIAAQE.
full dataile upon which you ~baep your claRn, It a C ern o (Glero
~~P~Y~'z r~arne.} ~ , ~ P~ y+~ v~-a: jnvolv~vq, givp~ tba
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8. 'What Wert weather condltlonc ilke~
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9. Give Warne and address of any wltnes~s; I'J1 [,~ C~~s n ~~„ ~ ,~ I ~ .... l _
1D. Did pollee lnvesti? {fE so, g~ names of atflc~.)
11. Was ar-ycnQ in)ur~? ~} ~, 91ve names, addresses, and extent of in
s i~~ 3rarie~s)„n °
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FROM GANSEN EXCAVATING
71. Was an
FAX N0. 3195568044 Jun. 07 2007 08:17AM P3
. • V 1..
injur®d~ (If sa, give names, aduresses, and extent of injuries),
1Z. Was any damagQ dnn. to property? (It so, describe property and the wctent
of derna$gs. Attach estimates of damag®s cr descrlbm basis far ascarkaining
extent of damage.} ~ ;
13. What ath8r damages do you claim, if any?
~, n ~/ r^ r
111.. Hav® you bean compensated for ~Iny part or a{I cf your ciuim ay any
insurance campanyl(If se, give harne and address of insurance company and
amount pgid,} '
1 ~. What amounf do yea claim from the City cat Dupuque?
_~
1 B. V1lhy da you trlaim the City 4f DubuquQ is responsible?
17. Have you mscde arty claim age"snst anyone elst for damages as a raeuiY of
this incidQnt?.(!Eyes, glue name and addresa.} ~^
18. if the answer to Question 1? is yes, have you received any payment frem that
scarce, and if so, in what amount?
Dated this day of .~(.d h P_ _ _.__~. ~ . 20~,
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Pas ry b
¢!t tend tAx n'anamitta: memo 7671 (yet ~. - ++ ..~
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