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# DUBUQUE COUNTY - DAMAGE CLAIM FORM

1. Date and Time of Incident: ___

2. Location of Incident: ___

3. Property Damaged: ___

4. Cost of Damage (attach estimates, receipts, photos, etc): ___

5. Description of Incident: ___

6. Did any Law Enforcement Agency that investigated the incident? If yes, list agency.

Submitted By (Print Name): ___

Address: ___

Phone: ___ Total Amount Claimed: $___

Signature: _____ 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







County Engineer