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Claim by Jayantibhai Patel Copyrighted October 7, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUM MARY: Nick Helgerson for property damage, William Hickson for property damage, Mary Kisting for vehicle damage, LJ R Investments, LLC c/o LinsyAdamsforpropertydamage, Jayantibhai Patel for property damage, Jhony Edgordo Ramirez for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Helgerson Claim Supporting Documentation Hickson Claim Supporting Documentation Kisting Claim Supporting Documentation LJR Investments, LLC Claim Supporting Documentation Patel Claim Supporting Documentation Ramirez Claim Supporting Documentation . ��� � t � ���� � {:�..l�ll� l4�'a��N�T �N� �:I� �F ��g���Ey ���/�i � 1 This written rep�c�rk coe�stitutes your claim again�fi the Cit� �f Dubuc�ue, lowa. You should � cor�plete this form �n full and attach any additior��l information that suppa�ts yaur claim. ' � 3 Th� C�aim rnust be filed with the City C[+�rk at City Hall, 50 V11. 'i3��' St., �ubu�{ue, IA 52(I�}1. �t � will then be referred by the City Council to the appropriafie depar�ment for investigafiion. � 4nce th�t investigat�on is completed, a repart and recommendation will be submittec! fio the � �ity Co�tnciL Yc�u wi11 be provided with a copy of that rep�� and rec�mmendation. ' � T'ME FI�AL C}�+CISIC}N �N A�L ��A�MS 1� BVIA�E BY THE C1Tl( �C}UN�IL. NC3 EMPLt)YEE t}F TH� �1TY OF DI��UGtEJE HAS THE AUTHt}RITY T� MA�CE A�1�' REPI�ESENTATI4N T4 YO1� , - AS T`f} WHETHEFt Y�lJR CLA�M.�/ILL.,{7Fi W��'L I�OT BE P,4ID. 1. Name of Claimant: �� � . .. s , � 2. Address: ���� �;�c� �� � � i City� ����� St�t�w �.��...: ���: ��.t��� � , ;� 3. Telephone Number: ��T��� ��`� ���'�'� ���p� -��"��'.�� � 4. Date tsf Bnc€dent; �� � %�'� :�''�i`� , , 5. Time of Incident: �'''" ���� � � 6. �c�cat�on of Incident 4Be �pecafic}: �r.�.� ,�`�'`����a;�.- , .��;�, �� • � � �'�. ���'�-��� ���- � 9 7s D��CRI�E ACCIDENT OR QCCUR�ElVC� TFiAT CACISED INJURY C1R DANIA�E. ��ive � fu11 detai�s u�on v�hich yot� base your claim. If a City empl�y�e w�� involved, gir�� th� � employ�e'� name.� � s a , � ,��c�.- �` -.�.a- �" �1 r.�-�' .�'.�+��.���' � i � � � r !� r' '� G8 � � $. Vl►ha� w�re r�veath�r conc9itions iike? �� ' � ,�� �. � � ~�` s 9. �ive name and address of any witnes�es: � 10. E}id p�1�ce inve�tlg�,t�? (If soa gi�re r��m�s ofi�ffic�rs.} � ; � ���,.�� ���� � � 19. Was anyone injured? (If so, t��ve names, address�s, and eactenfi af injuri�s}. � ��� ��� � , �.� � _ ���. � � � � , � 1�e ldgdas any damag� done to property? {If so, descri�e prope�ty and the extent of � d�r�ag�s. Attach ��tamat�� of dannages ar describe ba�is far �scer�aining exte�t of ' damagen} � � � { � ��.�. � > ��".���-' �'�-� ; �� d 1 ! 13, Vi�hat �ther c�aa�ages dc� you �laira�, if any? --�- � � � � � � �1�4. ��ve yoa� beer� corr�p�nsated far a�y p�r# ar al9 of ya�r clairr� by ��y �n�urance 'i co�pany? {If so, gi�re name and address of rns�rance company and amount paid�) �� � i �� 'I�'� , ; '15e What �rnount dc� you cla�m fro�n the �ity of C�ub�que? � , /r��� ' �_�� �:,�°� � � ;3 __ , , , 16. �t11hy do you c���e� th City �f C1�buque i� re�pc�n�ible? .,� �.-��?� -� ,:F c� ��.. � g� 1°Td Have yo��rnac9� any ctaim against an�o�+e else for damage� �s � r.esult af this i��idet�t� ; �1�y�s, give ��r�e and �ddr���.} " �� 1�p If the ansvver t� Qu�estior� �7 i� y�s, �ave you re�eivec� ar�y paymer�t fro�n that �c�ur�e, ? an�d of�e�, �n vvhat am�s�nt? � � E ;. u I�a�ed a� ����r�ue, Is��nra thi� ,��� e�a� e�f �� C�„�� , 20,�. � ; f i � ( �M � ` * �� {�It�P1�tl.4C'�} � � �m...,. , ���c��•-�-i `ht-�c�:�,t �� . ����� {F�rer�t Name} -� �� � �: � � ��� � �"� � � � ,�,� ; � (E? � s;,, � � .� %� �"J.� , � � � � � (t�ev, 511�} �. � �. �; � � � j � i � � g a � � � � �i�l"��1!'��11t1�� ' ; 1'his communication and �ny at�achments may c+�ntairt infc�rmation whic� is �o�fidenti�l � and priv�leged b� I�w and �� for the use �f the de��gnated re�ipient. If you are r�at #he ir�tended recipient, you are hereby notif�e+d th�t you h�ue received this comrr�unicatior� ir� � error, and that any r�v'ew, d��closure, d�ss�mtn�ti+�n, dostr�butwan or copy�ng of �t� contents is prohibited. ��ease nc�tafy City of Qubuque imm�d�ate�y by tel�phone at �563}-5�9-4°�20 �sf ;i y+�ur r�ce�pt af these ��ems and de�#r�y the commur��cation and any att�chrr�e�t� � � immediatel}j. Further disclasure of this informa�ion may v�otat� state �nd federal re�tr�ctic�nsa � � 1 } �c�nf�dential infarmatic�n r�ay include the fo�lc�vvir�g: ' � '�� Social �ecur�ty Number{�) ; �) �edicallNealth Infc�rm�tic�n � ,� 3) Per���n�B1C�iscip�inary Informat�on ' 4) B�r��Account Infc�rm�tic�r� 5} Financ�al Information � �} Credit Card Nurr��er� � �r � ; �f �r�y do�umentation you desire to �ubmit tc� th� �ity of C�ubuque contains any of the iterr�� abave th�� cover she�t must b� at�ached d�rectly tc� the confidentia� �nfarmatic�r� and indicate the type af i�formatio�a that �s includ�de � I �.-� � �� `�� � �� J , � � �� ��'� hereb certi that the afitached document� 1 , „ � Y �Y � ir�clud� the foll�vrring prc�tected information: � �; S��ial �ecuraty �lumber{s) ��ank Account In�carmation � ��dical/Health Informatior� F��ancial Infc�rmation '� Personn�f/[�i�ciplinary �nforr�atic�r� Credit Card 1�umb�r{s) � � � I ur�derstand that th�� i�forrt�ation may be distrfbuted within the G�ty c�rganizatie�n c�r t� agenfis of th� � City for proce�s�ng ar�d 1 her�by authoriz� �he �ity t� act accc�rdir�g6y ta4�ing alt precaut�t�n� to � prc�tect my informa��c�r� from unnece�sary distrik�utior�. , � � � � �._.,� � � � ���� �� � � � � � ��a ;�.� , � �ignatur� �ate , § � � � � : � � � � � � i, � � � Copyrighted October 7, 2019 City of Dubuque Consent Items # 3. ITEM TITLE: Disposition of Claims SUMMARY: CityAttorney advising that the following claims have been referred to Public Entity Risk Services of lowa, the agent for the lowa Communities Assurance Pool: Nick Helgerson for property damage; William Hickson for property damage; Mary M. Kisting for vehicle damage; LJ R I nvestments, LLC c/o LinsyAdams for property damage; Jayantibhai Patel for property damage; Jhony Edgordo Ramirez for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo Dubuque THE CITY OF �... � -�""� � All-A�e�ica City � �a..� � � wm�wu.cnncu;a:xx: 1' II�•r zoo�•aoiz•�ois Masterpiece on the Mississippi 2o1�*Zo19 6 � e TRACEY STECKLEIN � PARALEGAL � MeMo p I To: Mayor Roy D. Buol and � Members of the City Council DATE: September 23, 2019 j , RE: Claim Against the City of Dubuque by Mark Topf '; E � Claimant Date of Claim Da#e of Loss Nature of Clairr� � � Jayantibhai Patel 09/23/19 09/05/19 Property Damage �' i� This is a claim in which claimant alleges tha#the door to room #21 at the Glenview Motel � was damaged when police used forced entry to gain access to the room. Police first obtained a search warrant before conducting a search of the room. I This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa , Communities Assurance Pool. ' cc: Michael C. Van Milligen, City Manager Mark Dalsing, Chief of Police Jayantibhai Patel OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TE�EPHONE (563)583-4113/Fa>c (563)583-1040/EMai� tsteckle@cityofdubuque.org � �