Claim by Michelle Green V
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �Ial �?
11, I
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.
i
The Claim must be filed with the City Clerk at City Hall, 50 W. 13t" 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.
i
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.
F
1. Name of Claimant: L 1,1h CYe Gly--
2. Address: q6ot`a..se N; 11 Ct, 0C`1mm: Q;b)j
C", A
3. Telephone Number: (O
4. Date of Incident: c�ober i(.o , a('1 t L4 k
I
5. Time of Incident: r kr X114 1 'a'. 5o
6. Location of Incident (Be specific):,.. q � tin( Y' c a aWT 1C-Y°, r`J�
P `
' f eta � B L ( Q. a.14-rc t i
F
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
i
full details upon which you base your claim. If a City employee was involved, give the
employee's name.)
i
i,'
8. What were weather conditions like? p ) e o -
9. Give name and address of any witnesses: 01A
10. Did police investigate? (If so, give names of officers.)
�-V
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
A,
i
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.) f
4
II
13. What other damages do you claim, if any? f
i
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.)
15. What amount do you claim from the City of Dubuque?
Do
�1
16. Why do you claim the City of Dubuque is responsible .
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) 1
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 2 n day of �, 3E E 20 .
i
f
t
t (Signature)
� i
(Print Name)
x
c)
C-)
(Rev. 7/12)
00I
cn
Cn
Confidential
This communication and any attachments may contain information which is confidential
and privileged by law and is for the use of the designated recipient. If you are not the h
intended recipient, you are hereby notified that you have received this communication in
error, and that any review, disclosure, dissemination, distribution or copying of its contents
is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
it
Confidential information may include the following:
f,
1) Social Security Number(s)
2) Medical/Health Information
3) Personnel/Disciplinary Information
4) Bank Account Information
5) Financial Information
6) Credit Card Numbers
If any documentation you desire to submit to the City of Dubuque contains any of the items above,
this cover sheet must be attached directly to the confidential information. Please indicate below the f
type of information that is included.
I, 1 f C�l r -1 r-e e X11 , hereby certify that the attached documents
include the following protected information:
I
f
Social Security Number(s) Bank Account Information
Medical/Health Information Financial Information
i
I
Personnel/Disciplinary Information Credit Card Number(s)
I understand that this information may be distributed within the City organization or to agents of the
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
i
Signature Date
I have read the information above and do not have any confidential documentation to submit to the
City of Dubuque as part of this Claim Against the City.
Signature Date