Claim by Kurt Becker~r~n
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You l%~~
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 Ofi:tce. 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.
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Name of Claimant:
2. Address:
3. Telephone Number.
4. Date of Incident:
5. Time of Incident: I l'~ % ~~ N I ' ~
6. Loca ion of Incident (Be specific): /'
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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, girve
the employees name.)/ ,,.~ ,~~ _ h _~ ~~ ~ 1i ~ ~•-~ ~+nx
8. What were ~pre~ie~r 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.) D (~~ `•r' C7
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11. Was anyoJ e injur d? (If so, give names, addresse ,and xten of injuries
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. W at other da , ages do you clai , if any? - '~ / ~ // - ~ ~~ ~ ~ - S4
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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.)
15.
16.
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I / . I"1dVe yVU ~ ~!CIUC ai iy ~,ia.n i i ayan ia- ai ~yv~ ~c c~~c
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 what amount?
Dated this ~~ ay o ~ , 20
(Signatur )
(Print N me)
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INVOICE
Adams Pet Hospital
5875 Saratoga Road
Dubuque,lA 52002
563 582-5500
Where Warm Hearts & Cold Noses Meet!
Printed: 09-24-07 at 10:32a
FOR: Kurt Becker Date: 09-24-07
11420 Rupp Hollow Rd Account: 8170
Dubuque, IA 52001 Invoice: 65557
Date For Qty Description Net Price
Services by Jerry Adams, DVM
09-24-07 Diego 1 Office Visit/Examination 38.50
09-24-07 Visa payment -38.50
Old balance Charges Payments New balance
0.00 38.50 38.50 0.00