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Claim, Colson, KarenCLAIM 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: Karen Colson 2.Address: 532 Kaufmann Ave. 3. Telephone Number: 563 556 4987 4. Date of Incident: 10-15-02 5. Time of Incident: 6:15 - 6:45 A.M. 6. Location of Incident (Be specific): Front Curb 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.) Wheel on garbage can was broke, can was fine until after they picked up my trash. I went out shortly after to bring it back and the wheel was broke. 8. What were weather conditions like? Good 9. Give name and address of any witnesses: None 10. Did police investigate? (If so, give names of officers.) No 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.) 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? $10.87 16. Why do you claim the City of Dubuque is responsible? My can was set out that I bought in August for this new program. Can was in excellent condition till my refuse was picked up, my can was on its side. I went to bring it back shortly after they were here and my wheel was broke. 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 16 day of October , 2002. /s/ Karen Colson (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 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. 3. Telephone Number: Name of Claimant: Address: ~-~ ~-~ ~:- 4. Date of Incident: / 2 - ./~ -- ~ ~ 5. Time of incident: 6. Location of Incident (Be specific): 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY O1~. ~(GiVe full details upon which you base your claim. If a City employee was inveh~d, give the employee's name.) 8. What were 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). //0 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.) 15. What amount do you claim from the City of Dubuque? 16. Why do you claim the City of Dubuque is responsible?/~ 17. Have e any claim against anyone else for darhages 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) ¥! 'enbnqnG O :iAib2L) I (Signature) (Print Name)