Claim, Schmerbach, Randy T.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.
1. Name of Claimant: Randy T. Schmerbach
2. Address: 10850 Key West Dr., Dubuque IA 52003
3. Telephone Number: l563 582 7620
4. Date of Incident: Sunday, April 20,. 2003
5. Time of Incident: 1:30 P.M.
6. Location of Incident (Be specific):
City metered parking lot across Bluff St. from Carnegie Stout Public Library
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.)
When parking into city-owned space I struck a pole and dented the rear bumper of my truck.
8. What were weather conditions like? clear, dry, sunny
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.)
Dent in base of rear bumper
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.)
None
15. What amount do you claim from the City of Dubuque?
$412.50
16. Why do you claim the City of Dubuque is responsible?
Damage caused by post that was left after removal or placing parking meters. If post was removed at the level of lot, not a 18"-24" high I would not have struck the post and dented my bumper.
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?
No
Dated at Dubuque, Iowa this 29th day of April, 2003.
/s/ Randy T. Schmerbach
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
I~PR-29-20B3 16:49 DUPRCO COMMUNITY CR UNION /329 584 2241 P,02/05
CLAIM AGAINST THE Ci~ OF DUBUQUE,'IOWA '
~his written repo~ constitutes your elalm agelnst the City of Dubu~ue~ Iowa. You should
complete this form In full and a~ach any addi~onal information that supports your
The Claim must be filed with the City Clark at C~ Ha[i, 50 W. 1~~h St., Dubuque, IA S2~01.
It will then be referr~ by the City Council to the appropriate department fo~ investigation,
O~ce that investigation is completed, a repo~ and ~e~ommendation will be submitte~ ~ the
City Council You will be provided with ~ copy of that repo~ and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL, NO EMPLOYEE
OF THE CITY OF DUBUQUE HAS THE AUTHORI~ TO MAKE ANY REPRESE~ATION TO
5. Time of Incident:
6. Location o! Incident
7, DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE, (Give
full delails upon which you base your claim. If a City employee was involved, give the
employee's name.)
What were weather conditions like? c.~_.~ 4~.~ , ~
Give name and addres~ of any witnesses:~
10. Did police investigate? (if so, give names of officers.)
11, Was, anyone In~ured? (If so, give names, addresses, and extent of injuries),
APR-29-200~ 16:49 DUPACO COMMUNITY CR UNION 319 584 2241 P.0~/05
12. Was any damage done to property? (If so, describe property and the extent of damages,
Attach estimates of damages or describe basis for as~.ertaining extent of damage.)
13, What other damages do you claim, if any?~.,,~
14. Have you been compensated lot any part or all of your claim by any insurance
company? (if se, give name and address of Insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque? .:. . ~
16, Why de you claim the.City of Dubuque is responsible? ~,,~_
17. Have you made any clam~ 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 reGeived any payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this.. ~z~/~ day of _.
(Signature)
(Print Name)
(Rev. 1100 & 71Ol)
DUPACO COMMUNITY CR UNION
584 2241 P.04×05
MIKE FINNIN FORD
UNKNOWN
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RPR-29-200~ i6:49
DUPACO COMMUNITY CR UNION
TOTAL P.05
DUPACO COMMUNITY CR UNION
w,#w. dup~o,eam
2241
Fax tol Karen Chee~rman, Deputy City Clerk
Company: City of Dubuq~
Date: 04129/2003
Nui~;ber of Pages: . 5 (including this cover)
From: Randy Schmerbach, Sr. Lendinq Consu!ta~t
Branch: 3299 Hillo~st Rd., Dubuque, IA 52001
If you have any questions or if you did not receive ali of the document, please oontacl the sender.
~-.~dide~dality NoUgat The documents accompanying this fax transmissk)n contain c~denti~l information be[ong[ng to
He sende~ which is le~latlY prlvilegecL The information is intended only for the use ot the individual or entity named above, if you
are not the intended rcclpient, you are hereby notified that any disclosure, copy or distribution, ot the taking of any action in
reliance on or regarding the contents of this faxed information is stricl~y prohibited. If yoU have received this tax in error, please
notify us immed{atoly by telephone to arrange for the tatum of the original document to us.