Claim Kilcoyne, MikeCLAIM 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: Mike Kilcoyne
2. Address: 472 Loras Boulevard, Apt. #3
3. Telephone Number: (563) 543 8415
4. Date of Incident: Sept. 2nd, 2002
5. Time of Incident: 10:00 P.M.
6. Location of Incident (Be specific): Rear - second floor window of building at 472 Loras Boulevard (at landing
on top of stiarcase)
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 don't know the employee's name; I do know that an officer entered through the rear window of the house, breaking it.
8. What were weather conditions like? normal, clear
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes, Becky Stieber
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.)
Yes, broken window at rear of buliding.
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?
$48.96
16. Why do you claim the City of Dubuque is responsible?
The window was broken out by a Police Officer
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?
Dated at Dubuque, Iowa this 7 day of 2002 , 20 .
/s/ Mike Kilcoyne
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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 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
1. Name of Claimant: [~*~-~,/~j~[ ,..h-o~. .
3. Telephone Number: ~~/5--Q~C~ ~-~
5. Time of Incident: ~: ~O ~r--)'~ ' ~'
s. Location of incident (Be specific): X r
~J
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.) . -- , // c. , , ~. . , _
8. What were weather conditions like? (3/d~
9. Give name and address of any witnesses:
10. Did p~olice inve.~.tigate? (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
corn pany? (If so, give name and address of insurance company and amount paid.)
t
15. What amoun, 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?
(~ YA~e/~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?
o~ ~'~ day of '2~(~ ~-
Dat~e~ at .[~?buq~e, Iowa this
(Print Na~e)
,2O
(Rev. 1/00 & 7/01)
Westside ~ass, :r~c.
4975 Radford Court
Dubuque, TA 52002
]:nvoice
DATE INVOICE#
[10/4/2002 I 13068
BILL TO
Ivlike Kileoyne
472 Loras Boulevard Apt. 3
Dubuque, IA 52001
SHIP TO
W'dl brhxg fi:ame ia 10-4-02
P.O. NUMBER TERMS
A-2705 Due on receipt
QUANTITY ITEM CODE
1 7/8" I0 mat(s)
DUE DATE REP
10/4/2002 DB
DESCRIPTION
24" x 27 1/2" installed in frame
Iowa sales tax
F.O.B. PROJECT
AMOUNT
PRICE EACH
46.19
6.00%
Thank you for your business.
Total
46.19T
2.77
$48.96