Claim, Riniker, Ronald R.CLAIM 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 recou~nendation.
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: Ronald R. Riniker
2. Address: 800 W. Locust
3. Telephone Number: 582-9061
4. Date of Incident: Sun. April 8 - Mon. April 9, 2001
5. Time of Incident:
6. Location of incident. Basement of Dwelling, 800 W. Locust
(Be specific)
DESCRIBE ACCIDEI~TOR OCCURRENCE THAT CAUSED IN~dkY OR DAMAGE.
(Give full.details upon which you base your claim. If a City
e~ployee was involved, give the employee's name.)
8. Weather: Rain.
9. Witnesses -
10. Police investigate: Police Officer sat in car by Sewer cover in front
of house.
11. Injuries: No.
10.
8. What were weather conditions like? ~l~
9. Give name and address of any witnesses.
Did police investigate? (If so, give names of officers.)
Was anyone injured? (If so, give name, address and extent of
injuries. )
13.
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 damage.)
Yes, basement had 2 1/2 feet sewage & water standing in it.
Furnace (1 yr. old) and Washer & DRyer) were damaged / ruined along
with clothing & personal objects and panel walls in 1/2 of basement.
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 amount paid. ) No.
15. What amount do you claim from City? $2784.60
16. Why do you claim the City is responsible:
City Sewer line was blocked right in front of 800 W. Locust causing sewer backup
in basement.
17. .Have you made any claim 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 ~nat amount?
Dated at Dubuque, Iowa, this 23rd day of April, 2001.
/s/ Ron Riniker
2001.
(Revised January, 2000)
(Signature)
(Print Name)
REGISTER PRINTiNE ~0. -- EAST DUBU~ ~ d1025 ;299958-DQ
SANITARY TOWEL SERVICE
GIANT WASH LAUNDRY
P.O. Sox 531 · 1887 Elm Street
CUSTOMER NAME
12797
CONTROL#
1
~0, 7.5
1~. 5-5
~JBTOT~£ 100,30 S
THIS IS YOUR RECEIPT
'. Thank You For Your patmnagel
GEISLER~B~s~I-IERS CO.
340 E. 12th St. ° Dubuque, Iowa 52001
Phone (319) 583-7363 · Fax (319) 583-7365
HVAC
lrtVOl~
INVOICE DATE
[] NO CHARGE
JOB#
PHONE
TOTAL MATERIALS
TOTAL LABOR
TERMS
NET DUE 15 DAYS.
FINANCE CHARGE OF 1V2% PER MONTH (ANNUAL RATE
OF 18%) CHARGED ON ALL ACCOUNTS OVER 30 DAYS.
Note
OUT (OR
REplaCED)? YE~ NO
LIMITED WARRANTY: All materials,
parts and equipment are warranted by
the manufacturers' or suppliers written
warranty only. The above named
company makes no other warranties,
express or.implied, and its agents or
technicians are not authorized [o make
any such warranties on behalf of above
named company.
[~ REGULAR [] WARRANTY
[] SERVICE CONTRACT ~ EMERGENCY
TOTAL
LABOr
,NVO,OE,~__~,2 '/~-/
A UtiliCo~ Un~d Company
[] CSC 800-504.-2000
[] OM 402-339-4357
[] LX 800-538-6329
~DB 877-757-7577
[] WV 304-877-5566
Service Provided:
Basic diagnostic check completed. Service Request:
j7
Appliance is now in worldng condition
· / ......
Wrk Code Service Description ~ ~ Charge Discount
· $ $
C.h[~ Checl~. DLg: MC [-~Visa
? To~
I A serfi~ eha~e of $15.00 ~ be ~ess~ on
] ad~tion to other fi~ ~d e~n~ pen~fi~ wMeh may be pe~ed by ~w.
Yo~ ~e buyer, ~y ~1 ~ ~on ~ ~y ~e prior ~ ~t of ~e ~ P~d
b~ ~y ~r ~e ~ of ~ ~om S~ ~e a~ nofi~ of ~Bafion fo~
br ~ e~l~fion of ~ fi~t R you ~ you ~y ~ ~ p~ ~ ~t notice by
Customer Si~amre: L ~/,:~ ~ I ~~ Da~: ~/] L/g /
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