Claim by Matthew and Amanda Saylor Copyrighted
October 21 , 2019
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUM MARY: Roxanne Ties Brenner for property damage, Matthew and
Amanda Saylor for property damage, Sheri Scheffert for
property damage
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City
Attorney
ATTACHMENTS:
Description Type
Brenner Claim Supporting Documentation
Saylor Claim Supporting Documentation
ScheffertClaim Supporting Documentation
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �' ��`�r'G�j°S
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This written report constitutes your claim against the City of Dubuque, lowa. You 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 W. 13'h St., Dubuque, IA 52001. It
will then be referred by the City Council to the appropriate department for investigation.
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.
1. Name of Claimant: ���f�hQ}A� � HfW 4�1/�/ C(j� � a��y
2. Address: o��� �nll/E,�SI���P �
CitY: �X� ' State: Zt1 Zip: �
3. Telephone Number �. � , - �
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4. Date of Incident: . (��"O�'�Q}' „2 �(1 f Gj
5. Time of lncident: y:](���� �tUPX' I.l'0.�"P Y (a62�v(7(� �l' ���'p -(� �} I�-��G]
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6. Location of Incident (Be specific): �'t� � I (j1QQ{� LX ��(-' � (`-�
h(; l>P . -
7. DESCRIBE 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.)
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8. What were weather conditions like? t'/�.�,n �.1,'1 :,_ ! nyl � U-iT �
9. Give name and address of any witnesses: ���;<-rpy {�ima}���qn �{'/'yy' ��gp
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10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, add�esses, 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.)
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13. What other damages do you claim, if any? �'��SSG (�. 11�Q �
14. Have you been compensated for any part or all of your ciaim 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 Du�u� 'H'��I (�G� ,��
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16. Wh do you claim the City of Dubuque is responsib e? ,
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`'�u(��p� 0��i�t� �'�e,w �l�c� u p � � fio � ur m�v{(�
17. Have you made any c ai gainst anyone Ise for damages as a result f this incide�t? J �
(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?
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Dated at Dubuque, lowa this ��ay of _ , 20�
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(Print Name) ',J. C; --� ,Ti
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(Rev. S/18) `D o
Confidential
This communication and any attachments may contain information which is confidential
and privileged by law and is for the use of the designated recipient. If you are not the
intended recipient, you a�e hereby notified that you have received this communication in
error, and that any review, disclosure, dissemination, distribution or copying of its contents
is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical/Heatth Information
3) Personnel/Disciplinary Information
4) Bank Account Information
5) Financiallnformation
6) Credit Card Numbers
If any documentation you desire to submit to the City of Dubuque contains any of the items above
this cover sheet must be attached directly to the confidential information and indicate the rype of
information that is included.
�, , hereby certify that the attached documents
include the following protected information:
_Social Security Number(s) Bank Account Information
_Medical/Health Information Financial Information
_Personnel/Disciplinary Information _Credit Card Number(s)
I understand that this information may be distributed within the City organization or to agents of the
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
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Signature � Date
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Copyrighted
October 21 , 2019
City of Dubuque Consent Items # 3.
ITEM TITLE: Disposition of Claims
SUMMARY: CityAttorney advising that the following claims have been
referred to Public Entity Risk Services of lowa, the agent
for the lowa Communities Assurance Pool: Roxanne Ties
Brenner for property damage, Matthew and Amanda Saylor
for property damage, Sheri Scheffert for property damage
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur
ATTACHMENTS:
Description Type
ICAP Referrals Staff Memo
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Dubuque h;
THE CITY OF N
AlbAneriea City ;
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2007*2�12*2013 �
Masterpiece on the Mississippi Zoi�*Zoi9 �
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TRACEY $ TECKLEIN
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PARALEGAL � ��
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MEMO
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To: Mayor Roy D. Buol and �I
Members of the City Council �,
DATE: October 9, 2019 I�'i!
RE: Claim Against the City of Dubuque by Matthew & Amanda Saylor
Ciaimant D
ate of Cla�m D
ate of Loss �lature of CI i
am
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Matthew & Amanda 10/08/19 10/02/19 Property Damage 'i
Saylor
This is a claim in which claimant alleges that a City sewer backed up into claimant's
basement at 2450 University Avenue.
This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa �
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
John Klostermann, Public Work Director �
Matthew & Amanda Saylor I'
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OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TE�EPHONE (563)583-4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org