Claim by Jill Jellisonl
l ~~~~
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constituin ful~and lattach any addit oral i formation thata. You
should complete this form
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 alt 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.
Name of ~
2. Address:
3. Telephone Number
4. Date of Incident:
~~ ~-~~
5. Time of Incident: ~C ~ ~~%~~ ~~
6. Location of Incident (~ specific): ~~~
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 name.) ,~ , Y . ~,-~ _ ~ , ~,, .~~
-~~~_~_.
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8. What were weather conditions lik~~~~
g,.,Give name and address o~ any witnesses:
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give 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.)
13. What other damages do you claim, if any?
<~~~~
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 Dubuque?
16. Why you claim the,of Dubuque is responsible? G~
4
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes,' give name and address.)
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
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Dated this day of , 20
~'I 'a,~~nunQ
(Signature)
£ I =ZI ~d L Z AOPI LO
(Print Name)
CJ~11I:~;J~d
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