Claim, Kelly, ElizabethCLAIM 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: Elizabeth Kelly
2. Address: 1673 Ruann Dr.
3. Telephone Number: 583 0374
4. Date of Incident: 7 16 01
5. Time of Incident: 1:55 P.M.
6. Location of Incident (Be specific): Carter Road & Corner of Kaufmann
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.)
The fire hydrant was getting cleaned out & the water hit my car and tore my power
steering belt.
8. What were weather conditions like? Sunny - Fine
9. Give name and address of any witnesses: 3 Fireman
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.)
No
13. What other damages do you claim, if any?
Just replacement & labor for power steering belt.
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 the City of Dubuque?
$58.25
16. Why do you claim the City of Dubuque is responsible?
There was no way around this and the force of the water caused the problem.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
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 6th day of July , 2001
/s/ Elizabeth Kelly
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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. 13~ 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: ¥) {~q~
2. Address: t673
3. Telephone Number:
4. Date of Incident:
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.) ~.~(= ~C~ k~C~R~~- ~L~ ~'~Q~¢F('~ ~[~~
U
8. What were weather conditions like? ~ ~B~ -- ~
9. Give name and address of any witnesses: 3 ~ ~
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
13. What other damages do you claim, if any? ,_~'~-J~ ~-'~IC~CC~'~' ~ /
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.)
15. What amount do you claim from theCityof 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?
(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
day of
~Signature)
(Print Name)
200/ .
(Rev. 1/00 & 7/01)
VAUGHN'S MR. MUFFLER
3155 UNIVERSITY AVE
DUBUQUE, IA 52O01
319-557-1836
INVOICE
DATE INVOICE #
7/16/2001 27133
BILL TO
KELLEY LIZ
1673 RUAN DR
DUBUQUE IA 52001
319-5834)374
319-557-9952 CALL
Year/MakeJModel
MI 108306
93 CHRYSLER LEBARON
EM]? GT
P.O. NO. TERMS
ITEM
K060815
DESCRIPTION
SERP BELT INSTALLED
SUBTOTAL
Sales Tax
QTY
1
RATE AMOUNT
54.95 54.95
54.95
6.00% 3.30
It's been a pleasta-e worldng with you!
Total
$58.25