Claim Runde, GeraldCLAIM 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: Gerald Runde
2. Address: 2088 North Star Dr.
3. Telephone Number: 582 8717
4. Date of Incident: Oct. 19, 01
5. Time of Incident: afternoon 3 to 5 o'clock
6. Location of Incident (Be specific): 2088 North Star Dr.
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 Companny ILLIowa were cutting erpansion in the street.My house got splatter with cement.
8. What were weather conditions like? Windy
9. Give name and address of any witnesses: Clarence Seitz, 2449 Briarwood, Asbury
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.)
Cement splatter onmy house and windows and a City Engineer look at it and it will have to power washed
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?
$159.00
16. Why do you claim the City of Dubuque is responsible?
They hired the company to do the work.
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 15th day of November , 2001.
/s/ Gerald Runde
The City should look at poles for street signs and also fire plugs. They also covered with cement.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
re crt constitutes our claim a alnst the Clt of D b ·
This written p y g ' ' y u uque, Iowa. Ybu sl~ould-
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: ~~
2. Address= C~O~<~
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.).~
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, 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?
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 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?
(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 ;;~~
,200 [.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Duke's Powerwash & Maintenance Service
1818 Vizaleea Drive
Dubuque, IA 52002
INVOICE '
IiCustomer
ame Jerry.~al~ ~-
ddress 2088 North Star
hone
ZIP 52002
Date 11/13/2001
Order No.
Rep
FOB
C~ty Description I Unit Price TOTAL
1 Powerwash concrete dust off house. Dust was caused $150.00 $150.00
by construction company removing expansion in street
in front of house.
r- '~ SubTotal $150.00 i
Payment Details
O Cash Taxes Sales $9.00
O Check
~ .~ TOTAL $159.00
PHONE: 563/583-8916 OR 563/599-4142
18% Annual interest will be applied to all unpaid balances on the 25th of each month.
THANK YOU FOR YOUR BUSINESS!
Payment due upon receipt