Claim Sand, Michael WCLAIM 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: Michael W. Sand
2.Address: 880 Goethe St. Dubuque IA 52001-8129
`
3. Telephone Number: 563 583 8425
4. Date of Incident: 26-28 Sept. 2003
5. Time of Incident: During the Daytime
6. Location of Incident (Be specific): Goethe & Windsor Left on Windsor to Davis St. Several Times & Goethe & Windsor, Right on Windsor to Intersection of Windsor & Burden 2 or 3 times
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.)
Windsor & Burden, 2 or 3 times from Goethe St. & Windsor & Goethe to Davis St. SeveralTimes, Windsor from Burden to davis St. Blacktop and Fresh Oil on Windsor. No workers on Windsor During those times and signage was not put on Windsor
and Goethe at any time.
8. What were weather conditions like?
Most days sunny or with sun and clouds
9. Give name and address of any witnesses:
No Witness that I know during those times but owner & Mgr. of Miracle Car Wash saw blacktop and oil and removed it on 10 1 03. His business
card attached to this form and receipt for reover.
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
None
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.)
Only damage done to my car on both Sides & some on some fenders
13. What other damages do you claim, if any?
None, only blacktop and oil to my car
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?
$107.00 for removal of blacktop and oil & wash & Was put on my car - See Attached Receipt
16. Why do you claim the City of Dubuque is responsible?
No signage placed on Goethe & Windsor at any time.
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?
--
Dated at Dubuque, Iowa this 3 day of October , 2003.
/s/ Michael W. Sand
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
This written report cOnstitutes your claim against the City of Dubuque, Iowa. '4i'~u 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: ,,~./E/Y~~/-
2. Address: ~¢¢'~ ~'~'//&~
3. Telephone Number:
4. Dateoflncident: ~Z,? .~£?~
7, DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INgURY 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 conditions like? ~5~ o" a~s ~'~;~
9. Give name and address of any witnesses: ~o ~7~wB;x
' P A~ 'g ' ( ' g' e 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 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?
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 _ ?_~
;-day of
L_ N (Signature)"
(Print Name)
(Rev. 1/00 & 7/01)
255 Locust St.
5: 22 pm 10-01-03
CAR~ 683 SLSMN~
Detail Wash 0.00
WaxroomSales 60.00
Fast Wax 40.00
SALES TAX ?.00
TOTAL $: 107.00
Check 107.00
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