Claim, Clement, RobertCLAIM 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: Robert Clement
2. Address: 3070 Kaufmann Ave.
3. Telephone Number: 587 0535
4. Date of Incident: 6-4-2002
5. Time of Incident: 5:30 A.M.
6. Location of Incident (Be specific): Kaufmann Ave. & Central - See Attached Map
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 on my way to work and the street either collapsed or there was a hole already there with no barriers. It caused my 2 passenger side
tires to blow out.
8. What were weather conditions like? Raining
9. Give name and address of any witnesses: Lt. Jeff Pillard of the Police Dept.
10. Did police investigate? (If so, give names of officers.) Yes, Lt. Jeff Pillard
A DCPR was filed with Officer J. Roth Bade #58A; The Case # 02-25271
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.)
2 Passenger Side Tires on my pickup blew out. I had to buy 2 new tires.
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? $145.03
16. Why do you claim the City of Dubuque is responsible?
There wasn't any barricades on the street at the time.
17. Have you made any claim against anyone else for damages as a result of this incident?
No(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 4th day of June , 2002.
/s/ Robert Clement
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AG~
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: ~O~F~T C~__F/tAE/tJ-~
3. Telephone Number:
4. Date of Incident: ~ - ~?- ~ ~
5. Time of Incident: ~d-,'_~ ~ ,~, ~ o
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 v~ere 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.)
/VD
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
(Rev. 1/00 & 7/01)
day of ,TZ)xC7~~--- , 20_~7_.
~ (Signature)
s?~si0 ~0 (Print Name)
BIG A AUTO PAR?S
INVOICE #:
Dubuque,
Iowa
52001
563-556-1123 DATE: C~
STARTERS AND ALTERNATORS PAGE: (~F:
NAME: CA~31 t, VEHICLE:
ADDRESS: LICENSE:
CITY: DLJBLQUE,~ IA 5E~OO~ V.I.N,:
PHONE 1: (319) EXT. ENGINE: TRANS:
PHONE 2: (319) EXT. MILEAGE:
QUAN. PART NUMBER DESCRIPTION PRICE OP TECH DESCRIPTION PRICE
8.0e ~6~ P2357515 13~, 2
SUBTOTRL 136. 8
X
LABOR : $
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~G PA~ & SER~CE SUPPLIES : $
~ "~e~.intheBusiness' TAX : $
QUICK L~E CA~ TOTAL :
OIL CH~GE ~ ~,t C~e 2nd Chan.e 3rd Change 4~ Ch~ge 15'h Chan~
$13.95513.95513.95513.95 FREE PAID : $
DUE :