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Claim Kane Kathleen MCLAIM 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: Kathleen M Kane 2. Address: 2013 Keyway, Apt I Dubuque Iowa 52001 3. Telephone Number: 319 557 9939 4. Date of Incident: December 24, 2000 5. Time of Incident: 3:30 - 4:00 PM 6. Location of Incident (Be specific): southway drive asbury, right side, north 150 ft on south way drive 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.) I was driving north on south way drive and made impact with a deep pot hole in the road whch was covered with a heavy blanket of snow. 8. What were weather conditions like? Snowing and Cold 9. Give name and address of any witnesses: john Kieffer , 37921 red lane, Holy Preire Iowa 52003 phone 552-1069 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 property damage 13. What other damages do you claim, if any?rear tire, encolsed is a copy of the tire damage. 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? $48.74 16. Why do you claim the City of Dubuque is responsible? because the street on south way drive was defective due to pot hole damage to my tire, three or four days later barricades were placed around the area 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 26th day of Jan , 2001 . (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. 3. Telephone Number. U/ ~, ,,5'S~'- ~' ~ ~ 4. Date of Incident:_ ~e~/~ ~ ~¢0 ¢ ,. Time of Incident: a 6. Catlon of inc dent. ~Be specific) ~o ,~ ~ g. '0%'- 7. DESCRIBE ACCID OR ~u~"-'~CE THAT CAUSED INJLTRY 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 like9 , - Was anyone inJured? (If so, give name, address and ezten.tTo~ injuries. ) 10. 11. 12. Was any d~mage 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. 14. 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 amount paid. ) 15. What amount do yOu claim from the City of Dubuque? 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, 20~/ . (Revised January, 2000) iowa, this (Print N STOR~ 4018 KEYWAY APT~i DUBUQUE 319~557~9939 AUTHOP~ZA~ON 072000129472 ~C COURTESY ECTtON MARK PISB/75Rl~ 40~000 MILE TRh~DLIFE LTD ~ARR [RE INSTALLATION $~R¥ICE PTP~ STEMS VS i: ~ ROAO HAZARO PR~EC'riON LIFETimE WNEEL ~A~ANCE PENSKE T~RE INSFALLAT%~N SERVI £NCLUDES l'tkE MOUNTINe LIF~FI~ Tt~ ROTATION,VALVF 5 LIFETIME ~HEEL DALANCE AND RO6D HAZARD' PROTECTION ~ ~ TiRE DISPOSAL FiRE HAS 2 SLICES iN APPE~tRS TO eE ZMPACT.SLILES ~!~ -so PLEASE PAY FRO~ TH~S iNVO ~H REGISTER I~PR%NT R~QU~RED ON 0 ACKNOWLEDGE PAYNENT'~D TO VA~ID o00 .00 31.99 's1.99 H~RRAN 3.99 2.16 t0.00 "THE LEADER IN A I/TOMOTIVE SER$~CE'