Claim, Breitbach, Zachary S.. May.21. 2301
8:05AM BARRY A L! iDAHL, Ne.3561 P. 3/4
This w~itten ~eport constitutes your elalm a~ain~t the City of
~u~e, I~a. You ~ould c~lete this fo~ in full ~ a~ch
The Claim must be filed with ~:he City Clerk at City Hall, 50
West 13th Street, Dttbuque, Iowa 52001-4864. It will ~he~ be
referred by the City Council to the appropriate Department for
investigation. Once that investigation is co=~l~leted, a rel~Ort and
~eco~endatlon will be submitted to the City Council. You will be
pr~v.lcle~ with a ~ODY of that report and reco~en~atio~.
-*'~u~ FINAL DECISION ON ALL CLAIM~ IS MADE BY THE CITY COUNCIL.
NO EMPL0~EE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE AN~
REPRESENTATION TO YO~ AS TO W~ETH~R YOU~ CLAIM WILL OK WILL NOT BE
PAID.
1. Name of Claimant: Zachary S. Breitbach
2. Address: 16280 Herod Ln
3. Telephone No. 582-8446
4. Date of Incident 5/18/01
5. Time of Indicent: 7:45 A.M.
6. Time of Incident: Southeast bound lane of J.F. Kennedy - 100-200 ft. north of
NW Arterial
7. Describe Accident: While driving on JFK Road, front right tire hit a pothole that
extended across the outside white line of JFK and onto the road. The tire sustained
irrepairable dame and the rim was bent.
8. What were weather conditio Excellent - sunshile.
9. Give name and adress of any witnesses: None, but while my father was inspecting the damage, another car hit the same pothole
and also received dame to his tire. This was within 3 hours of incident.
10. Police investigate: No.
11. Injuries: No.
....
BARRY A LINDAHL, BSQ No.356] P. 4/4
Was any damage done to property?
Tie was damaged and cannot be repaired. The rim was also bent. We have not yet replaced the tie,
13.
14.
Have you been compensated for any part or all of your claim by
any insurance company? (If ~o, give name and ad~ress o~
insurance company an~ amount paid.)
15. What amount do you claim from the City of Dubuque?
$370
, ......
16. Why do you claim the City of DubuqUe is responsible?
,
19. Have ~OU ~e ~ ela~ainst ~e else ~Or '~ages as a
result of ~s ~c~d~t? ., ~ ~ ..
I£ yeH, g~ve ~ame and addref$t
18. If the answer ~o Question 17 is yes, have you reeeive~ any
payment ~rom that souzee, and if so,
in what amount?
/s/ Zach Breitbach or contact Paul Bretibach (father) 556-8672 Ext. 20
(~is~. Janua~f, 200~')