Claim by David J. Schmitt 3 17 09
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 13t" 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 year claim wil! or wil! not be paid. f(
1. Name of Claimant: ~av ~ ~ ~ . Sc1A,nn ~ ~"
2. Address: 3~~~~ Qa~-e~S .5+. ~~~~lu~uP i ~i~. S.2dDa
3. Telephone Number J~(o 3 ' S S~ - D ~u~
4. Date of Incident: / ~ -a2D - ~ ~ ->'w~, ~~-o~ ~ -~ 9
5. Time of Incident: ~~ - O~,P~
6. Location of Incident (Be s ~ecific):
~~Q~ '~hnurla 5. p a ~e l~.~buq u~-, ~~ ~~DD1
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 ~ame.) `~
P;D~s -Fa o~~'e c~eV'e ~a,~~on,~ c~ o , Ca )~~ ~D~ ~-4~oc~e~, ~~~
GGlvh ~ O tom. -{, ~t-~ ~ ~l-f"1, o ~ ~ ~PC. a ~d c ~ea Gteo` /r o- ~ a.r~ c~ r~u ~ C~i.Gvie u'cL
o(raN-1 `Fl^.e I;+~r_ ~~~ ~a~ol -~~.p~rc ~i-~ctS a ~focl~aG~ ~ti ~~~~ S~~'',~e~~`f~~
'(,u~I~eol ,~~.~ ~r~y -Flee s~h-F SoVheD/~~ ou.~F CG~4G~ G~n.~ ~;1~-1~.~`-`7`-rtv-o~
fie c~~y ra.~eUa was b/'o~e - ~ p~~ bevfo •G~oo-t~,r ,~a b'~"^~9 ou~~ r:.ar~e~~, .
8. What wefrfeJweather conditions like? ~~ ate'`-~'`"`"r
/Nrh~'~~
9. Give nam a d address of any witnesses:
~V"~GI.Y~ ft-I~c~r.St~ av~d~ l~P~ ~~ ~irol~~
R o-1'o f('oo`f~e.vr - Da/'de( ~nv-~C~p ~'~ke~~ n0. d~SbX 1533 ~~~~i~ ~A 5~a~~/
~,~y ~J~1<~~s 1~~~~~ ~~.PF- ~g;il l~~~l~y, ~op~4., Jo~.w Klas~~r;~~~~~
10. D police investigate? (If so, give names of officers.)
1\~a
11. as anyone injured? (If so, give names, addresses, and extent of injuries)
~\/ D
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:)
n~
13. What other damages do you claim., if any?
No ~,~
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.)
1 .What amount do you claim from the City of Dubuque?
.~ 1, v oil .7.3
a .
16. Why do you claim the Ci y of Dubuque is r sponsible?
~J eC ~ ~e. i n S `r ~e ~~e 1M,av- ho fie. •~~r~v-e u~a~ a~' ~eq S--F r ~'.
~.~ ~1o~s;s~~~/ef~~q ~.~n~l l?~oc~lr~.q rn~ Sewer ~~~es~+~~tsl~~a ~hpo+~
_-E'o ~o~ C ~h a in ~_.J~~ ~F ~ v~ -t,~~J_~~~ he . ?(~,' I I I~C e~~+ uDw. ~~tV~Z- r,. -~f'V cti~r free ~d /, I,-i
={'~n~S w~5.-~~Q PNob~ew, o~lnol ~~' W~IS caUSeG~ .by 11c.~< a-F p~~c.~ aHO( ~~~Gv~iti 7"t ~
17. Have you made any claim against anyone else for damages as a result of• ry`~~h ~~I~
this,Aii i ident? (If yes, give name and address.)
UV v
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Da d this a 7 day of ~~~ v`~av-~/ , 20. Del . ~ °
(Signature) ~ ~.:~ --~ ~
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(Print Name) ~ ~- fl
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AND ASSOCIATES INSURANCE
Dubuque • Bellevue • 888-556-6660
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CR/HNEII~M~{/~1UAL
'°+~.„o~ Mw~a~~~, .ems' AEINSU AANCE~CUYPANY
u www.Ludovissyandassociates.com
Locally Owned and Operated ROTO-
HORKHEIMER PLUMBING, INC. ROOTER®
D.B.A. ROTO-ROOTER
SEWER-DRAIN
SERVICE
" ~nd ~war~ CJo ~aoudlesDown tle `Dwain "
P.O. Box 1533 • Dubuqlue, Iowa 52004 • Phone 563-552-1828
• TV Camera Inspection & Video Recording
• High Pressure Water Sewer Cleaning • Electric Sewer Cleaning
CUSTOMER'S
ORDER NO. DATE ,~~ ' 120 ~
ADDRESS ~ ~ I ~ f /`'I/~ nn~ S ~4_.._ ~C~
I
HERE'S THE PROBLEM I FOUND AND FIXED. CHARGES
YOUR: WAS CLOGGED BY: sink .......................................$
^ sink' ^ grease ~ tub ................................. 4
^tub or shower ^food ~~~~~~~~
^ toilet ^ paper or sanitary p . ucts toilet ......................................$
^ laundry /washer lines ^ hair
^ floor drain 0lint floor drain ..............................$
^ septic lank line ^tree roofs , ~ laundry ..................................$
~mainsewer line ^ foreign objects
^ other ^ sludge s ptic line ....................:........ ~' ~
^ soap residue ~ e
~~ ,~ ~m~n sewer .......... ..............$ ~~~~,,
,other ~ ~% `°
$
TOTAL FOOTAGE CLEANEt•• ~~ KNIVES USED- '
JOB DESCRIPTION AND REMARKS: ~ ~ ~ ~ rr ~ ~ ~ ~. v { ~_ -
$
~, ~ ` C% ~ TOTAL ~ ~ ~I
j-
CUSTOMER SIGNATURE _ ~ OPERATORSIGNATURE~---~°
a. .._
r~~a
~u~cr~c~~~ "~ 3A~ YS ,~ tiil ~~ ~ ~ Dom. w . ~~ ~ ~p ~ ~ PLEASE PAY FROM THIS INVOICE
~.. ...,
A service charge of 1 112% per month (18% per annum) will be charged to all accounts past
30 days. Costs plus reasonable attorney fees to be added in case of suit for collection.
Locally Owned and Operated RO'rO~
HlORKHEIMER PLUMBING, INC. ROarER®
D.B.A. ROTO-ROO i r.R
.SEWER-GRAIN
SERVICE
"~nd way ~'o ~aoudles mown ttie `Zlaain "®
P.O. Box 1533 • Dubuque, Iowa 52004 • Phone 563-552-1828
• TV Camera Inspection & Video Recording
• High Pressure Water Sewer Cleaning • Electric Sewer Cleaning
CUSTOMER'S
ORDER NO.
~ '' --.
DATE ~ ~ <-~ ~0
NAME ~ ~ ~ ~ ~ ~. ~ `~? ~ ~~•,~~-- 1-- ~ `~~ ~-~i ~~
ADDRESS .~ ~ 7 ~ ~~~~ Mme. ~-, ~ ~ ~ E~~ ~ .!-~LJ~'
HERE'S THE PROBLEM I FOUND AND FIXED. ~,,,,~ CHARGES
YOUR: WAS CLOGGED BY: sink .......................................$
V,~ `
^ sink ^ grease
'"'~~., tub .........................................$
^ tub or shower ^ food
-,
^ toilet ^ paper or sanitary product ilea ......................................$
^ laundry I washer lines ^ hair -
^floor drain ^ lint floor drain ..............................$
^ septic tank line ^ free r s-~ ~ laund
l ry ..................................$ _ .. _.
in sewerline eign objects ~ ~
r~ , _
oth r ^sludge ~-1~ ~~ septic line ..............................$
^ soap residue main sewer........~ ...............$'~ ~~ ~'~
^ ocher /
-TOTAL FOOTAGE CLEANFD• ~ • KNIVES USED --% ~ ~
JOB DESCRIPTION AND REMARKS: , ~. ~
i~ v
f `.'`~~ Vii;". `_;~y,.{, #~~~ ~:=f'~a~l ~,~• C 1~f~ti-~ ` v
~- 7
k, r`T ~r r 7 a-t--~ t ~ $
- e ~. r C"Ct , ice. i 1 f -'~ k ~ ~ . l~ ~. ~,y,,
~t1~ J ~ ~ ~" ~~ ~ ~ !
tlc~`~ r± ..-r~ ~"! v t d ~`~ ~~ "'~.. ~? ~ ~" ~ TOTAL
CUSTOMER SI~I~ATURE OPERATOR SIGNATURE' ~- ~ „~
_ _ ~
~~~ ~ ~ 3 ~. ~~ ~0~ ~ AMOIt~I,.,w_T 9'PLEASE PA FR M THIS INVOICE ~
CURRENT '~ _ ~~~;. ._....: - __.__. ,~
A service charge of 1 112% per month (1tl% per annum) will be charged to all accounts past
_= 30 days Costs plus reasonable attorney fees to be added incase of suit for collection r~ ~