Claim, Wolbers, SheilaCLAIM AGAINST THE CITY OF
DUBUQUE
This writtenreport constitutes your claim against the City of
Dubuque, Iowa. 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
West 13th Street, Dubuque, Iowa 52001-4864. 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 w-ith a copy of that report and recommendation.
T~E FINAL DECISION ON ALL CLAIMS IS MADE BY TItE CIT~ COUNCIL.
NO EMPLOYEE OF ~E CITY OF D~UQUE
~PRES~ATION TO YOU AS TO WRE'~R YO~ C~ WILL OR WILL NOT BE
PAID.
1. Name of Claimant: Sheila C. Wolbers
2. Addres: 1250 W. 12th
3. Telephone: 582-4689
4. Date: Dec. 4
5. Time: 6:30 A.M.
6. Location: 12th Street west side left side going up
7. DESCRIBE ACCIDENT OR OCCURENCE:
I left my apartment for work and when I moved my car forward to go down
the hill I felt it bump something on the right front. Thinking it was nothing I continued a block or so on .....
when I knew my tire was going flat. A policeman called McCanns for me and he came took the tire.
(Give full details upon which you base your claim. If a City
~loyee was involved, give the ~loyee's n~e. )
9. ~ive n~e ~d ad, ess of any witnesses.
10. Did police investigate? (If so, ~ive n~es of of~rs~
O
Was anyone inj~ed? (If so, ~ive n~e, ad,ess ~t~ o~
injuries. )
12. Was any damage done to property? (If so, describe property
and the extent of d--unage. Attach estimates of damages or
describe b,~sis for ascertaining extent of damage.)
I reported the broken curb to city street dept.
13. None
14. Compensated: No
15. Amount claimed from the City:
$146.06 for tires and labor plus $26.50 service call total bill $166.56
16., Why do you claim the City is responsbile: Curbs along 12th are cracked & falling out.
17. Have you~made a~y claim against anyo~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 i~ sg, a.rt~vha~ amount?
Dated at Dubuque, Iowa, April 24, 2001
2001.
/s/ Sheila Wolbers
McCANN'S CITGO IOCO
690 west Locust St.
DUBUQUE, IA 52001
Day (319) 557-8383
Night (319) 588-1794
AMOUNT
rOTAL PARTS
TOTAL LABOR
TOTAL LABOR
TOTAL SUBLET
GAS, OIL ,
__A_~ GREASE .....
SHOP BUPPLtES
TAX 7