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Claim - LeFevour, KellyCLAIM 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: Kelly LeFevour 2. Address: 1084 W. 3rd St. 3. Telephone Number: 585 1336 4. Date of Incident: 1-4-01 5. Time of Incident: 5:45 6. Location of Incident (Be specific): Curb in front on U.S. west Building on 9th St., corner of Locust and 9th 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.) Pulled up to curb to park. The structured rod of the curb had been pulled back and recovered with snow immediately popping my front left tire. Officer Latham took pictures of exposed rod. 8. What were weather conditions like? Clear, cold. 9. Give name and address of any witnesses: Alex Wonio, 1110 1/2 University, Nick Gibbs, 1037 Kirkwood, Nick Wagner, 2737 Linda Ct. 10. Did police investigate? (If so, give names of officers.) Yes, Officer Latham: a male officer on duty. 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.) Yes, ruined tire. 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.) No 15. What amount do you claim from the City of Dubuque? $114.48 Price of one tire, Uniroyal TigerPaw, for Ford Explorer. 16. Why do you claim the City of Dubuque is responsible? Snow plow workers tore the curb apart leaving a sharp dangerous rod exposed, and the rod was hidden by snow. 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 5th day of January, 2001. , 20 . /s/ Kelly LeFevour (Signature) (Print Name) (Rev. 1/00 & 7/01) 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 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: 2. Addr.ss: 3 · Telephone ~,~her: 4. Date 0~ InCident:- 5. Time: of Incident:. 6. 7. D~-SCRIB~-/~CCID~T OR OCCURR~NC~,'THAT C~US~D INJurY OR (~ive, full details upo~ which you base your cla~. If a City ~ployee was involved, ~ive the ~loyee~s n~e.) 9. Give ~=e and address of any wi~esses. ~W/~Wb 10. Did police investi~ate~ (If so, ~ive n~es of officers.) 11, Was ~yon~ injured~ (If so, ~ive n~e, address ~d ~xt~t of in~u~i~s. ) 12. Was any d~ge done to property? (If so, describe property and the extent of damage. Attach estimates of damages or describe basis for ascertaining extent of damage.) 13. What other damages do you claim, if any? 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 ~mount paid.) 16. Why do you claim the City of Dubuque is responsible? 17. Have. you ~d~ ~y claim agains~ :~yone else-for d~ages as a result of this incident~ ~ If yes, give name and address= 18. .If the answer to Question .17.i~.~e~ h~ay~ you received any "pa~en~ f~:that'source, and if so, in. what amount? Dated at' Dubuque'; Iowa, this day of ~i~nature) (Print Name) (Revised January, 2000) ' ANDeM TIRE & AUTO SERVICE INC Depend on us!