Claim by Vernon E. Puls~~ ~v~~
~r
CLAIM 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 West 13th St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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: ~' ~e. r ~. ~ v.~ ~ . ~~ ~ ~
r,^,
2. Address: ~ l~ ~ ~, ti ~~„~ d ~ ~
a ~ ~ u~~ ~ ~~F e
~ ~,
3. Telephone Number~(~ ~, ~ ~ 5s,~ - ~ ! {2~ ~ <~
s ~ i""1
4. Date of Incident: ~1- ~ ~ - c~ ~ ~ v1~ ~
5. Time of Incident: `~' ~. ~J~. ~ _._.. ~
6. Location of Incident (Be specific):
~~ a~ z ~~~ ~ .r ~~~ ~~
7. Describe the accident or occurrence that caused injury or damage. (Give full
details upon which you base your claim. If a City employee was involved, give
tChe employee's name.)
~Cl cry ~ a ~t~ ~ v.~~4~ ~. ~cv~ ~ ~ (~ v~ ~ r `c l~ ~ ~e ~ c~ _T_ T
~~~ S~ r o~~ ~ ~I
~s!1 ~,ss~y v. ~, a~' ~ Q r c, ~
8. What were weather conditions like?
9. Give name and address c?f any wifnesses:
3 S e.`~''v', ~~ T•'1 ~5~'~.r e.rnQ I o ~ e,~.S C b ~s'r h ess c a ~ d 5 ~~ ~ ~~, e.d
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 damageL.) \
N~~~~"ov,~ ~,1~Vv~S a'v. ~~0~`(' b~cc~.~n~ c..C~~n~aVv~~~Ay~r~ a'~~
l.~a ~~.
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.)
Q ~e.ya ~~ t~ r e v~ a W ~ ~, {"_~~`~~~ ~~ ~~4~---T-~14 L1L°1~1~ ~~
15. What amount do you claim from the City of Dubuque? ,}
"'~•~~~ r a~~ ~ .Q ~ o~ ~ c~ ti c "k" ~ ~`?e S V~~ '~'~. ~a a. vin n "~~! +-~ ~ ~ ~ c~ (1 _ ~ c^
16. Why do you claim the City of Dubuq`uey~is responsible?
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1~Y 'C a~~~ n n o .a S S~'~r ~,~ , ~ ~ ~ S it u~ ~ r , ! ~ ~Q ~5 \,.~ O 1 ~~ O T ~ \~ V^
17. Have you made any clay\im against anyone else for damages as a result of
this incident? (If yes, give name and address.)
1\> n
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated this i_ day of ~ ~- h ~ , 20~_
(Signature)
(Print Name)
13. What other damages do you claim, if any?
Se~"?>ZCBMASTER Matt Heinold
~^an Cleaning Technician
Residential/Commercial ServiceMaster
Cleaning Services of the Key City
1845 Washington Street
Dubuque, IA 52001
563/557-1488
Fax: 563/557-2507
S~'vZ~eL ~ c~7+~•R
~-~~iJ Michael Armstrong
Clean General Manager
Residential/Commercial ServiceMaster
Cleaning Services of the Key City
1845. Washington Street
Dubuque, IA 52001
563/557-1488
Fax: 563/557-2507
S~''vZCBMASTER Chris Laugeson
Clean Cleaning Technician
Residential/Commercial ServiceMaster
Cleaning Services of the Key City
1845 Washington Street
Dubuque, IA 52001
563/557-1488
Fax: 563/557-2507
I
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CPen~e
Every Day Matters
jcp.cc~m
JCPENNEY #2144
KENNEDY MALL
555 JOHN F . KEfVNEL~Y
pUgUQUE, IOWR 52002
Phone 563-588-4157"7
**Catalog Invoice #345825940
Qty,, 1.: Kg Bedspread S 79.99T
~;at# `r~X703-1173D
Ln 01-7 l 11,50 6.40 >
Mdse Total 79.99
Ship/Hdlg 11.50
Subtotal 91.49
Sales Tax 7.000;6 6.40
Delivery Date 05/07/U8 X7.89
flour Mastercard # XXXXXXXXXXXX1792
was billed for $ 97.$9
on 05/06/08
~~,~~~~~~~~x~~~~r~~~~~~~~~~~~~~~~~~~~~*~~~~
~~~~~~r~~~~~~~x~x~~~~~~~~~~~~~~~~~~~~~~~~~
Save 159 by telling us about your
shopping experience at
www_JCPSurvey_com
Type directly into the address line.
Do not use web search to access.
Access code valid for 7 days
Access Code:2144 700 5801 050708 1420 0
H Yc Yf YCY(~ yc 7C 7(7C YC Yf lYY(YCYCYf Y(Yf YC Yf ~ % X fC Y( Y: Y(1C'Y. Yc fC Yc X Yc X X 1C 7t ]t Yc
7tYC~YC~YfYC~~IC Y(YI YC YC 7t 7K~KY(71'7(Y(YCY(1KY(1t .t Yl Yl YC )C Y; YI IK YC YC YC YC ~7C
Store:'2144 Term: 700 Tran: 5801
Date: 05/07/08 Time: 02:20 PM Assoc: 0110
Questions or Carnrnen-ts
Email our Store Manager
ddmarsha®jcpenney.com
JCPenney gladly accepts returns/exchanges
within 90 days of original purchase.
Return privileges for this receipt expire
on:
08/05/2008
Returns without a receipt will be refunded
at the lowest on sale price within the
last 30 days, and be given in the form of
a JCPenney Merchandise Return Voucher. No
refunds 90 days after original purchase
date.
For exceptions to this policy please refer
to customer service information on jcp.corr~
or in a major catalog.
~l Vl ~-~~I t~ .
Save money. Live Bette, .
SUPERCENTER
WE SELL FOR LES5
MANAGER GUS HUMBLE
PRAIRIE~DU2CHIEN40wI
~Ta 0882 OP# 00000159 TE# 25 TR# 04581
HAIR COLOR .030997869554 _ 2...97 X
jR~LE'CGOTHS OU4704202554 12 46 ;f(
TAX 1 55UBTOTAL w,. ` -1,:93
500 X 0 88
DEBIT TEND 16.81
CHANGE DUE 15'81
o.ca
EFT DEBIT ~- l~
ACCiJUNT PAY FROM PRIMAIFY
16.81 TOTAL PURCHASE92
REF # 813700532762
NETWORK ID. 0055 APPR CODE 057001
05/16/08 15:49:29
# ITEMS SOLD ~
TC# 2722+ 41815 2300 8288 5498
III~IIIIIIIIIIIIIIIIIIIIIIhIIIIIIIIIIIIIIIIIIIIIII i ' 'I
Econom l c stimulus check III~IIIIIIIIIIIIII~~II~iIII~I~iI~f h~~~
Keep all of your monea$ We scan help.
05/16/08 15:49:33
g
2900 Dodge Street
Dubuque, IA 52003
563/557-8222
PROD ID QTY UM PRICE TOTAL
BROOM,24" GARAGE PALMYRA
75060509 1 EA 13.49 13.49
SPRING GARDEN MUM
44995236 4 EA 1.99 7.96
SOIL,GARDEN SOIL MIRACLE GRO ROSE
_:410265_ _.___1 EA .99_ .99
SUBTOTAL _
22.44
Tax f~'.44 C 7.000% = 1.57
7% Sales Tax .1.57
TOTAL 24.01
Cash 30.00
Cash Change -5.99
05/03/08 13:07:35 001 19500661001
1 Theisen's Valued Customer
INVOICE #: 3692820 WSID: D8IPNNCI
E6842415-CC27-40D&-BA44-A5EB67C97C1E
0097SM 2.82.2946 TILL IC: 08
Please sage vour receipt fer proper credit!
Visit us online at ur~rta.theisens.com
THANK YOU for choosing THEISEN'S
Helping Io~aa Groin Since 1927
Illlll~lll~ll~llil ililll!lill
KOHL'S
Thornton
Thornton, CO 80241
(303) 255-9700
05-10-OS 11:21A 0345/000416195/4 1693XXX
ID# 999-9489-9188-7859-9654-9538-0479
MISSES SWEATERS 809956045456 C $.80 T1
MISSES GV DENIt9 609715263917 * 21.99 T1
SUBTOTAL 30.79
T1= 30.79 @ 8.6% TAX 2.65
TOTAL 33.44
GIFT CRRD XXXXXXXXX8604 29 .18
APPROVED 602918
NEW BALANCE OtJ XXXXXXXXX8604 0. 00
GIFT CARD XXXXXXXXX7281 4. 26
APPROVED 007074
NEW BRLANCE ON XXXXXXXXX7281 70. 74
FOR RETURNS WITH A KOHL'S MDSE RETURN
CREDIT CRRD OR GIFT CARD, A KOHL'S MDSE
RETURN CREDIT WILL BE ISSUED FOR THE
URLUE OF YOUR RETURN.
~IIIIIIIPII~IIIIIIIVVn!II~YINIIInII~IV~llll
r~~~r~~~DS - Du~uQUE
5300 Dadge Street
Dub~..tc~tae ~ I }~ 5~OC13
KEEP 'T`OUR .R,'tCEIPT
RETURN POLICY VARIES 6'T` PRODUCT TYPE
Allowable returns for items on this
receipt will be in the form of an in
store credit ~.+oucher if the return
is done after 08122/08
I~ I~I~I ~~ I ~~~ ~~i ~~ ~
Sale Transaction
4173082 9 C~1~.99 ,: 96.41-
10" FREt+1IUtd BASKET TD
2622146 7.99
10" PP,Et+!IUt+t BASKET '~ TD
2622146 7.99
TOTAL
TAiC AT 7%
TAL SALE
NETWORK ID 0028
REF# 052470253001
114.89
8.04
122.93
122.93
05/24/08 08:41:41
APP CODE 031338
TOTAL NUt+1BER OF ITEt+1S = 11
TD _ 30 day cver the counter exchange
products may be returned or exchanged
within 30 days of purchase with a
receipt. No returns, refunds,
exchanges, or credits will be issued
without a receipt. After 30 days,
merchandise may be sent out for repair
at the Guests expense, ur;less covered
under warranty.
THANK YOU, YOUR CASHIER, SAfiOY
30887 09 3864 05/24/08 08:40At+1 3057
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~~~~~I.~r,~}' FORFS.~[~.`~T t~LJ~'FI1'I~R~
CABELA'S RETAIL, INC.
33901 State Hwy 35
Prairie Du Ghien, WI 53821
608-326-5600
ST#0004 OP#033800 RG#0007 TR#001145
090093984 7PKT HIKER PANT KH 1T $29.95
UPCq 000000809579341039
002414466 CARGO PANT/BftTN/44 1i 519.95
UPCq 000000827624783320
Original Price: $34.95
Cabela's Specisl Prica
002475104 WNANDBTMOC/PL/8.5/ 1T $39.95
UPCq 000000827624955574
Subtotal $89,85
Tax 54.94
Total S9q.79
Mastercard Credit Card 94.79
Acct# *~M~~~~~~~*~1792
Auth~ 016813
# ITEMS SOLD 3
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040071146
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r to Cabela's!
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at
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Visit one o a~tail Showrooms
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Place a catalog order at 1-800-237-4444
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Save money. Live better.°°
WE SELL FOR LESS
MANAGER ROBERT HARDING
( 563 ) 582 - 1003
ST# 2004 OP# 00003937 TE# 24 TR# 04571
BROOM 007464280006 4.33 X
BATH RUG 004269420197 9.-88 X'"
20X34 RUG., ,.._D01089253081 9.88 K
7PK-BRIEF XL 00?603115050 6.22 X
`MENS SOCK .007603141042 6.00"}{
'PANTY 007533803189 '`6`9fi 7t
GV FF MILK 007874235189 F `3.14 0
BANANAS 000000004011KF
2.14 lb @ 1 !b /0.64 1.37 N
COFFEE FILTR 007128785988 1.04 X
AEROSOL 002240000523 3.08 X
PLUNGER 085707600090 2.66 X `'
ORANGE JUICE 004850000139 F 3.12 0
GU SQ2 MAYO 007874228312 F 1.78 N
ICB CRM BTR 004060034500 F 1.92 0
GV SNK CRKR 007874235259 F 1.18 N
ICB CRM BTR 004060034500 F 1.92 0
GFIC COFFEE 004300000082 F 2.88 0
GFIC COFFEE 004300000082 F 2.88 0
ICE CREAM 007756725445 F 3.50 0
MCC/SCH RED 005210007091 F 1.98 0
MCC/SCH CELE 005210000706 F 2.82 0
GV OLIVE OIL 007874242786 F 4.28 0
GV PARSLEY 007874243430 F 1,78 0
TOMATO SAUC 0024000342$6 F 0.72 0
GRLC/HRB SCE 002700042274 F 0.98 0
4 VIDALIA 003338360155 F 3.40 N
WAS 3.94 YOU SAVED 0.54
PRESSNSEAL 001258770441 2.62 X
CELERY 003338365322 F 0.99 0
2.65 lb RT 1.18 lb 3.13
LOWEST PRICE 0.99 lb 2.62
PEAR DANJOU 000000004416KF
WAS 1.38/lb YOU SAVED 0.39
2.65 lb @ 1 lb /0.99 2.62 O
BANDAGES 038137005635H 1.50 T
3.30 lb AT 0.58 lb 1.91
LOWEST PRICE 0.39 lb 1.29
GREEN CABBAG 000000004069KF
3.30 lb @ 1 !b /0.39 1.29 0
2.17 lb AT 1.22 lb 2.65
LOWEST PRICE 0.99 lb 2.15
APPELE BRAE 000000004103KF
2,17 lb @ 1 !b /0.99 2.15 0
SUBTOTRL 100.87
TAX 1 7.000 % 3.79
TOTAL 104.66
DEBIT TEND 104.66
CHANGE DUE 0.00
EFT DEBIT PAY FROM PRIMARY
ACCOUNT 1782
104.66 TOTAL PURCHASE
REF # 812200596358
NETWORK ID. 0055 RPPR CODE 222006
05/01/08 11:07:22
# ITEMS SOLD 3~
il~~YpII~VIIA'RIiV11~~NIIUI'uIiINIIN~N
05/16/2008 15;20:29