DUBUQUE COUNTY - DAMAGE CLAIM FORM

  1. 1. Date and Time of Incident: ___
1. Date and Time of Incident
  1. 2. Location of Incident: ___
Location
2. Location of Incident
  1. 3. Property Damaged: ___
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3. Property Damaged
  1. 4. Cost of Damage (attach estimates, receipts, photos, etc): ___
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4. Cost of Damage (attach estimates, receipts, photos, etc
  1. 5. Description of Incident: ___
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5. Description of Incident [1]
5. Description of Incident [2]
5. Description of Incident [3]
  1. 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