Claim Meyer, ArmellaCLAIM 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: Armella Meyer
2. Address: 636 North Burden
3. Telephone Number: (319) 582 5949 Son Tom Meyer 556 3467
4. Date of Incident: 10/00
5. Time of Incident:
6. Location of Incident (Be specific): Removal and replacement of North Burden
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.)
North Burden was removed and replaced in the fall of 2000. After repairs were completed - many cracks in plaster in living rooms in front of house.
While jackhammering to remove old street and driveway - items fell out of medicine cabinet in bathroom.
8. What were weather conditions like? --
9. Give name and address of any witnesses: N/A
10. Did police investigate? (If so, give names of officers.)
N/A
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
N/A
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.)
636 North Burden. Many cracks in plaster wall in the rooms on the north side. Cracks were NOT there before replacement of street.
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?
Repair cracks and paint walls
16. Why do you claim the City of Dubuque is responsible?
Yes... City Street was replaced.
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?
No
Dated at Dubuque, Iowa this 7 day of March, 2001.
, 20 .
/s/ Armella Meyer
(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.
2. Address: &J& ~/O~h
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of incident. (Be specific) ~e~0~)~/
7. DESCRIBE ACCID~ OR OCC~R~OE T~T CAUSED IN0uRY OR D~GE.
(Give full details upon which you base your claim, if a City
~ployee was involved, ~ive the ~ployee's n~e.)
8. ~at were weather conditions like? '~---
9. ~ive name and address of any witnesses.
/
10. Did police investigate?
11.
Was anyone injured?
injuries. )
(If so, give names of officers.)
(If so, give name, address and ~nt pf ~
12. Was any daznage done to property?
13.
(If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
~at other d~ges 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.
16.
What amount do you claim from the City of Dubuque?
Why do you claim the City of Dubuque is responsible?
7
17.
Have you made any claim against anyone else for damages as a
result of this incident?
If yes, give name and address:
,4/°
18. If the answer to Question 17 is yes, have you received any
payment from that source, and if so, in what ~unount?
20 Of
(Revised January, 2000)
(Signature)
(P'rin%' ame)