DUBUQUE COUNTY - DAMAGE CLAIM FORM
1. Date and Time of Incident: ___
1. Date and Time of Incident
2. Location of Incident: ___
Location
2. Location of Incident
3. Property Damaged: ___
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3. Property Damaged
4. Cost of Damage (attach estimates, receipts, photos, etc): ___
undefined
4. Cost of Damage (attach estimates, receipts, photos, etc
5. Description of Incident: ___
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5. Description of Incident [1]
5. Description of Incident [2]
5. Description of Incident [3]
6. Did any Law Enforcement Agency that investigated the incident? If yes, list agency.
6. Did any Law Enforcement Agency that investigated the incident? If yes, list agency
Submitted By (Print Name): ___
Submitted By Print Name
Address: ___
Address
Phone: ___ Total Amount Claimed: $___
Phone
Total Amount Claimed
Signature: _____ Date: _____
Date
Return this Form To: Dubuque County Engineer 1225 Seippel Rd Dubuque, IA 52002 engineer@dubuquecountyiowa.gov Phone: (563) 557-7283 Fax (563) 557-19
Department Comments: ___
Approved Denied Site Reviewed Mailbox Installation/Location Approved
Denied
Site Reviewed
County Engineer
Date
Mailbox Installation/Location Approved
Secondary Roads Superintendent
Date