Claim, McKillip Auto DiagnosticCLAIM AGAINST THE CITY OF DUBUQUE
This written report 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 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: McKilup Auto Diagnostics
2. Address: 402 W. 17th St.
3. Telephone No. 329 583-9679
4. Date of Incident: 3-30-01
5. Time: 10:00 A.M.
6. Location of incident. (Be specific) Southwest Side of Building.
7. DESCRIBE ACCIDENT' OR OCCURi~ENCE TIIAT CAUSED 'rNJU'R¥ OR DAMAGE.
Boulder fell from City property, rolled down hill and busted a hole in cement block wall.
8. Weather: Sunny & Dry.
9. Witnesses: Richard Soppe, Jerry Car & Joe McKilup
10. Police investigate: No.
11. Anyone injured: No.
O. What were weather conditions tike? t~]A/~&
11. Was anyone injured? (If so, give name, address and extent of
injuries.)
12.
Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent of d~mage.)
Damage to building was a 4 x 4 foot hole in Cement block wall.
13. What other damages do you claim, if any? 3 Hrs. Labor for cleaning & painting?
14. Have you been compensated for any part or all of your claim by
any insurance company? (If so, give name and address of
insurance company and amou-~.t paid°) No.
15. Claim from City: $879.00
16. City responsible?? The boulder fell from City property.
17. Have you made any ciaim against anyone else for damages as a
result of this incident? No.
If yes, give name and address:
18. If the answer to Question 17 is yes, have you received any
payment.from that source, and if sO, in what amount?
Dated at Dubuque, Iowa, this 27th day of April, 2001.
/s/ Joe McKillip
2001.
(Signature)
(print Name)
(Revised January, 2000)
K~LU C"K CONSTRUCTION
14285 HWY 20 WEST
PO BOX 1045
DUBUQUE~ iA 5200~1045
Invoice iD: 92286
Draw ID:
Customer ID: TRIS0'J
To_'
Td-State Auto D~nostics
402 W 17 St_
D~buque, IA 52001
Job Location:
l~em
To repair cement block wa~l h~ by bolder
roerig off of h~t.
Unit of
Units Measure Un'ri Price
Amount
879_00
DATE DUE: 5-t3-2001
Retainage Held
Amount Due
$879.00