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Claim by Bonjour Estates__ _ _ _ _ _ _ _ __ _ _ ___ 1~ _ _ ____ _ _ _ ~~ •,, ~,~ -~iIM ~(J CLAIM AGAINST THE CITY OF DUBUQUE, I!~~''`y ~'~~ This written report constitutes your claim against the City of Dubuqu~~l~aa`~ot.~l~ 1C~ ~ 3 should complete this form in full and attach any additional iniformation that supports your claim. ~~'~,, ~;r, ~.~±iit~~ to C~'.;'~~~,~{~_:,~:, I~ The claim must be filed with the City Clerk at City Hall, 50 West 13 St., Dubuque, IA 52001. It will then be referred to the appropriatie department for investigation and to the CityAttorney'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: 2. Address: ~a~~ r`~// ~~~ .1 ~G O ~r~if ~ ~, ~` 3 ~' ~ 3. Telephone Number, 4. Date of Incident: g/ ~/ ~~ ~ ~~~~ r 5. Time of Incident: ~~ 3 -- .~ S 7..- 7 I ~2- `r~r/ 6. Location of Incident (Be specific): y ~ 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 the employee's name ~ ~L~-c~ ~~ `d„s~~ 1~c~~ '~"~~.~..,•,...~. -.mss ~-r-Il-- Sot- o G ~ ,Q-=~e~ 8. What were weather conditions like? s~ 9. Give name and address of an witnesses.: - ~~~..,,._.s-e~._.. ~2s rte... -~-~2-ti-n-~= 10. Did police investigate? (If so, give names of officers.) 11. Was,gnyone 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. Wr~t~ they 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 amo w%9i~ ~) 15. What amount do you claim from the City of Dubuque? 16. Why do you claim the City of Dubuque i~, responsible? 17. Have you made any claim against anyone else for damages as a result of this inci ent? (If yes, give name and address.) D 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 ~ day of , 20 0 ~-~- (Sig (Print Name) ~j, ~j~~%'~y c-`~~-~~'~-Y 08/03/2008 19:09 0675831067 LYN PAGE 01 .~ ~ ~ -~-~~~ ~~~ ay ~ ._..._.___ .______._~-____...~_.~.._ ,Me em w Police Department 7^~T T~ E Uwe%f~5~me~t Center Mn~~ery+irre mr dK Missispi+lri Dubuque, Tows 5?Q04.0875 (563)589-4497 fax (563)589-4415 dispalth 911 EmerKency ;. Jeff Tupper 1f21A ~~~ .h `~. Patrol Officer ,~, y y ~ ~ ~ ~.~ ~ ~~, a., ~: ~ : ;,tip ~ ~;~, ~~' n e -~. , ~~~ ~ ~ w~ ~ ~ ~ ~~~ ~~ ~~~~~ ~ ~~ ~ ~ ~ ~~ ~, ~ ~~,~d~~ ~t1. ~~I cx>Vti w~, (wY~L ~/ ~ 1/ //~/ 1)1/x`. V I V ~~ ~ ~ ! V Y ~~ V` V v w ~ d ~ ~ 9 ~° ~~~ ~ ~ ~ !~-~ ~~ Nd ~w~ 1` y ~n ~,~ ~~~~ ~~ ~y ~~C~,l c~ .~ .,..~.. il~ (563) 556-6168 950 MAIN STREET -DUBUQUE, IA 52001 HANDYMAN ' ' 1-800-556-61 fib Fax: (563) 556-4680 .. , email: kanndoincdbq®ao[,com website: www.kanndoinc.com , ..- Client Name: ~ Q T Billing Address: ~Q ~ V b~ >F ~ city .~~G2 state S~ zip -52003 Job Phone: S y.2 ' 7 /~ y Other Phone: Contact: Phone: ~ ~ ~ ~ ~2 '^~ 11E-L-N ~ Job Address City State Zip E-mail Address: Cleaning Date:, Estimate: dash ^~ MasterCard # Check ~ VISA Expires Total amount due upon completion of services. A linance charge of 1.5% which is an annual percentage rate of 18%, will be charged on the amount of this invoice starting 30 days after the invoice date. OTHER ~~g. g ~ ~~f'fj~ KANNDO Professional Services wants to serve you better. Please read the following consumer awareness information and initial it. When was the last time your carpet was cleaned? How was ft cleaned? ' Alert technicians of liquid spills because we may have to use a process to prevent wicking. Carpet Cleaning Please move small items, knick knacks, antiques, breakables, etc. For ideal drying conditions: set your thermostat at 72', use fans and dehumidifiers, especially in basements. Please leave blocks or plastic sheets under furniture for 24 hours or until dry. The KANNDO method of cleaning carpets will deodorize & sanitize your carpet. We cannot repair worn fibers through cleaning. Cleaning will not repair color loss due to fading, chemical damage, pet stains or any other permanent stains or color changes due to BHT, and / or foreign materials embedded in carpet that may wick up and cause red, blue, green, yellow, etc. spots. Upholstery Cleaning Due to the unpredictable nature of upholstery fabrics and dyes, KANNDO makes no representations or warranties regarding the upholstery cleaning to be performed. By initialing where indicated below, the client acknowledges that client assumes all risk associated with the cleaning and hereby releases KANNDO from any and all loss, damage, or expense sustained by client as a result of the cleaning. Payment due upon completion of the job. THANK YOU! Cleaning Date: Estimate: Cash ~ MasterCard # Check ~ VISA Expires Total amount due upon completion of services. A finance charge of 1.5% which Is an annual percentage rate of 18%, will be charged on the amount of this invoice starting 30 days after the invoice date. OTHER When was the last time your carpet was cleaned? How was it cleaned? Alert technicians of to prevent wicking. liquid spills because we may have to use a process Carpet Cleaning Please move small items, knick knacks, antiques, breakables, etc. For ideal drying conditions: set your thermostat at 72', use fans and dehumidifiers, especially in basements. Please leave blocks or plastic sheets under furniture for 24 hours or until dry. The KANNDO method of cleaning carpets will deodorize & sanitize your carpet. We cannot repair worn fibers through cleaning. Cleaning will not repair color loss due to fading, chemical damage, pet stains or any other permanent stains or color changes due to BHT, and / or foreign materials embedded in carpet that may wick up and cause red, blue, green, yellow, etc. spots. Upholstery Cleaning Due to the unpredictable nature of upholstery fabrics and dyes, KANNDO makes no representations or warranties regarding the upholstery cleaning to be performed. .. By initialing where indicated below, the client acknowledges that client assumes all risk associated with the cleaning and hereby releases KANNDO from any and all loss, damage, or expense sustained by client as a result of the cleaning. Payment due upon completion of the job. THANK YOU! I have read and understand the above and have received complimentary Blue File Folder Thank you for calling essional Services!!! KANNDO Prof SUB TOTAL 9 ~J ~ ~~ TAX 2 ~' 9 2 GRAND TOTAL 100% Guarantee KANNDO Professional Services wants to serve you better. Please read the following consumer awareness information and initial it.