Claim Monte Carlo RestaurantCLAIM 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: Monte Carlo Restaurant
2. Address: 378 Main St., Dubuque, Ia 52001
3. Telephone Number: 319-583-9532, Home 319 556 3812
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific): 378 Main Street, Dubuque, Iowa 52001
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.)
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.)
yes, there are severe vertical crackes int he north and sound salls of the structure.
We do not have the estimate of dambages because we do not own the property.
13. What other damages do you claim, if any? Loss of income and inventory
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? to be determine
16. Why do you claim the City of Dubuque is responsible? Received letter from the city of dubuque
on january 17th, 2001, that notified us of the esat thirty feet of the structure must not be occupied
until further notie due to severity of cracking.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) not at this time
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 29th day of January , 2001
CLAIM AGAINST THE CITY OF
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 T~ CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WHETHER YOUE CLAIM WILL OR WILL NOT BE
PAID.
4. Date Of InCident:
5. Time of Incident:
6. LoCa~ of inciaent. {Be specifi&~ S~)--~O~.-~.J~j
7. DESCRIBE-~CCID~ OR OCC~ENcE'~T cAUs~ IN~Y OR
(Give full details upon which you base. your cla~. If a City
~loYee was involved, give the ~loyee's n~e.)
What were weather conditions like?
Give b-~e and address of any witnesses.
10. Did police investigate? (If so, give names of officers.)
11.
Was anyone injured? (If so, give name, address and extent of
injuries. )
12. Was any ~=~=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.)
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. )
15.
What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
result of this incid~t? No~ ~ ~%~p,,
If yes, give name and address:
18. If the answer to Question 17 is~yes, haye~.you r_eceived any
paym~n'~:f~'~hat:-'~0~urC'e~, a~d'~if so, in what mnount?
Dated atDubuque;'-Iowa,
20 01 ~.
(Revised January, 2000)