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Claim, Woerdehoff, John J.CLAIM AGAINST THE CITY OF DUBUQUE, IOWA 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 W. 13th 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: John J. Woerdehoff 2. Address: 1764 Avalong Road, Dubuque, Iowa 52001 3. Telephone Number: 573 582 4686 4. Date of Incident: Jun 15, 2001 5. Time of Incident: 8: a.m. 6. Location of Incident (Be specific): 1700 block of Avalong Road 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.) City Sewer line became clogged which created sewage to back up into my home through my basement shower drain and stool, and into the carpet. 8. What were weather conditions like? Fair 9. Give name and address of any witnesses: City Sewer maintenance employees that opened clogged line. 10. Did police investigate? (If so, give names of officers.) No 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). No. 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.) Sewage water soaked a portion of carpeting that floors the entire basement. Service Masters bill is attached for repairing damages. 13. What other damages do you claim, if any? None. 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.) My insurance does not cover this. 15. What amount do you claim from the City of Dubuque? The amount of bill, $236.50 16. Why do you claim the City of Dubuque is responsible? The City is responsible for the Sewer line in the street. 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 what amount? Dated at Dubuque, Iowa this 28th day of June, 2001. , 20 . /s/ John J. Woerdehoff (Signature) (Print Name) (Rev. 1/00 & 7/01) CLAIM AGAINST THE CTTY 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 P~%DE 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. 2. Address: .O_ 4. Date of Incident: ~]~.4m. /~ ~OO/ 5. Time of Incident:.~;..~ 6. Location of incident. (Be specific) 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.) 8. What were weather conditions like? 9. Give name and address of any witnesses. 10. Did police investigate? (If so, give names of officers.) 11. Was anyone injured? (If so, ~ive name, address and extent of injuries.) 13. 14. Was any d~mage done to property? (If so, describe property and the extent of da~nage. Attach estimates of damages or describe basis for ascertaining extent of damage.) What other damages do you claim, if any? 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=lt paid.) 15. What amount do you claim from the City of Dubuque? 16. why do you claim the City of DubUque is responsible? 17. Have you made any claim against anyone else for damages as a result of this incident? /~O 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? Iowa, this ~ day of (Revised January, 2000) SERVICE MASTER OF THE KEY CITY 1845 WASHINGTON ST. DUBUQUE, IA 52001-3662 (319) 557-1488 Inv'o[ce ~ DESCRiPTiON Water damaged .carpet cleaning PR S b-C° FaC °r Dubttque Local and State Sales~Tax P.O. NO. TERMS PROJECT QTY RATE 92~64 138:30 6:00% AMOUNT 138:30 4 (1):Thi~tnk' ybu for choosing Se~,iceMaster of the Key C ty Have a great day!