Claim Ellis, AmyCLAIM 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: Amy Ellis
2. Address: 3565 Seville
`
3. Telephone Number: 556 4799 wk 584-3475
4. Date of Incident: 9/9/03
5. Time of Incident: @ 12:30 P.M.
6. Location of Incident (Be specific): Across from Neighbors house - 3535 Seville Dr. (Sewer)
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.)
Was getting mail at lock box, pulled up to mail box - got mail through window of care, house in front of me had cars in driveway so since my
house behind me did three pt turn in st. - wheel hit sewer & metal rod sticking out of concrete and my front
tire blew.
8. What were weather conditions like? Fine
9. Give name and address of any witnesses:
No
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.)
$64.14 = tire and labor
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.)
No
15. What amount do you claim from the City of Dubuque? $64.14
16. Why do you claim the City of Dubuque is responsible? Rod sticking on of concrete is dangerous
and shouldn't be sticking out.
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?
NA
Dated at Dubuque, Iowa this 11th day of Sept. , 2003.
/s/ Amy Ellis
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE¢-IOW/~ '
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.
2.
3. Telephone Number:
4. Date of Incident:
Name of Claimant: ~Y~ (_/{ ¢1 1 ~--~_
5. Time of Incident:
6. Location of Incident (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
What were weather conditions like~ ~
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
b
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 damage~.
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. WhatamountdoyouclaimfromtheCityof Dubuque? ~l ~'/' [~7~
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.) //~C)
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
day of '
/~(Prin~t N~me)~ l / ' ~ '
(Rev. 1/00 & 7/01)
2900 Dodge Street
Oubuque, IA 52003
593/557-8222
oROD I0 @TY UN °~ICE TOTAL
TIRE,VERTEX IV P205/BBR15 ~W
3152379 ' EA 52,95 52.95
LABOR,SPIN BALANCE
3159961 I E^ 6,99 6,99
SUBTOTAL 59,94
3% Scles Tax 4,20
TOTAL 64,14
Check --64,14
09/09/03 '7:55:12 001 09091755211
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