Claim, Robertson, ToddCLAIM 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: Todd Robertson
2. Address: 2448 Pinehurst Ct., Asbury, IA 520021
3. Telephone Number: (563) 582 6216
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific): Stall 336 Locust St. Parking Ramp
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.)
Paint was spattered on my 1991 Nissan 240SX. Received a note from the parking division explaining the
cause of the damages.
8. What were weather conditions like? Windy
9. Give name and address of any witnesses: N/A
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.)
Paint was spatted on my 1991 NIssan 240SX
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.)
No
15. What amount do you claim from the City of Dubuque?
See attached estimates
16. Why do you claim the City of Dubuque is responsible?
Received a note from the Parking Division explaining what happened.
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?
N/A
Dated at Dubuque, Iowa this 29th day of October, 2002.
/s/ Todd Robertson
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST'THE CITY OF DUBUQUE, IOWA ~' ~ '"~ /4~.
You
This written report constitutes your claim against the City of Dubuque, Iowa.
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:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific): $~-~\\ ~ L~c~ ~-~r ,~ ~
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 were weather condi.tions like? ~c~_~
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 ~amages.
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? $~ o.~-~ ~-~% ~ ~
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 ~c~ day of
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
610 E. 14th Street Phone: (563) 582-0775
Chuck Ostrander Owner
TICKET # DATE: /~ - ,~ ~ ~o ~..
DEALER: .'~-'~
YR. AND MAKE AUTO//~/...;~ '7,-.~ ~..~ COLO~
COMPLETE DETAIL .'~~
PAINT $ TOUCHUP $
DELUXE WAX $
ECONOMY WAX $
ULTIMATE WAX ~ $
CLEAN MOTOR ~'~ (/ $
SEAL MOTOR /' . ~ $
PAINT MOTOR (. ~- ~,.,5"2~//d---~-,~--"~-~-~~ $
COMPLETE MOTOFF~ $
SHAMPOO SEATS
SHAMPOO CARPETING
COMPLETE INTERIOR SHAMPOO
CLEAN TRUNK
$
$
$
CLEAN VINYL TOP
ARMO PALL INTERIOR
NEW CAR DETAIL
$
$
OTHER $
SPECIAL A-I-FENTION TO:
INSPECTED .
SUBTOTAL
SALES TAX
TOTAL
THANK YOU FOR YOUR BUSINESS
IF YOU [lAVE ANY COMPLAINTS OR SUGGESTIONS
P1,EASE ASK FOR C} IU('K OSTRANDER
Truck & Car Accessories
3185 Hughes Ct. #C ° Dubuque, Iowa 52003
590-7457 (563) 690-0057
Bill to: (~,, i"x~-'C~c ~ ~ '
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Year Make Stock # i Job Description