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Claim Wilhelm, Mary Kann, KeitCLAIM 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: Mary Wilhelm and Keith Kann 2. Address: 255 Villa St. 3. Telephone Number: (563) 582 6111 cell #543 5701 4. Date of Incident: March 13, 03 5. Time of Incident: Called City at approx. 8:30 a.m. 6. Location of Incident (Be specific): Front yard between sidewalk and rock wall, at 255 Villa 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.) Broken water main leaking for a long time. Undermining our home and yard and producing a 40 ft deep by ? hole. 8. What were weather conditions like? 40-60 degrees...sunny 9. Give name and address of any witnesses: Kathy Walbrun, 540 Samuel, 52003; Joe Hickson 743 Cleveland Ave. 52003, Kevin Jaeger 17448 JOhn Deere Rd. 52001 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.) Sidewalk needs replaced, rock wall cracked and torn down, gardens dug up, grass needs re-seeding, many plants dug up. 13. What other damages do you claim, if any? Very concerned about property value, and house value. And any future problems. 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? $500.00 to rock botom, 2645.76 to Jaeger + $500.00 to replace yard misc. plans and mulch etc. 16. Why do you claim the City of Dubuque is responsible? Found break in City Water Main up the street from damage. 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) No 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? N/A Dated at Dubuque, Iowa this 20th day of March, 2003. /s/ Keith J. Kann (Signature) (Print Name) (Rev. 1/00 & 7/01) CLAIM AGAINST THE CITY OF DUBUQUE IOWA ' This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this fo~'m in full ~nd attach any additional information that supports your'claim. The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation. THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO 'YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 2. Address: 3. Telephone Number: ~54,$') ~ ~ - 4. Date of Incident: ~ 5. Time of Incident: ~:~ ~ 6. Location of Incic~ent (Be specific): 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 weathefconditions like?- J~/~ ~- ~o ~or~r~ 9. Give name and address of any witnesses: ~'~ b3~\~rur~ ~ ~O ~0~ - 10. Did police investigate? (If so, give names of officers.) S~.ml 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). 12. ,W~a.s a.ny t:lamage 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? c ¢em ooP© 1~. ~hy ~o you claim the Oit~ 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.). ~0 18. If the answer to Q~estion 17 is yes, have you received any payment from that source, and if so, in what amount? Dated[et D _u~u_ que~, I~wa this c~O day of - (Print Nal~e~'- -- (Rev. 1/00 & 7/01) Performed At: PAYMENT IS DUE UPON RECEIPT I Carl Heisler · 15582 Humke Rd. · Dubuque, IA 52002 (563) 583-9428 · Fax 563 588-4233 17448'S. John Deere Road Dubuque, IA 52001 (319) 583-6677 Fax (319) 583-5495 JOB INVOICE 13650 A~OUNT TERMS OF SALES Off sERVICE: CASH UPON cOMPLE' TION. CREDIT AccoUNTS ARE DUE ON THE 1ST OF THE MONTPI. MAXIMUM CREDIT (90) DAYS, 1-1/2% SERVICE cHARGE AFTER 10TH OF THE MONTH IS DUE. I hereby acknowledge the satisffact°~/completion o~ the above described ~vork.