Claim Cesaretti, PaulCLAIM 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:
2. Address:
`
3. Telephone Number:
4. Date of Incident:
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 employee's name.)
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give 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 , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
a ainst th DUBUQUE;IOWA ,
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 YO~,R CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: ~,~,~]~. ~/~"~/~,~/~'7-"~/. .
3. Telephone Number=
4. Dateoflncident: //~/~:)/,/~,/4A'~"~/~ /~"~., ~t~_~
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
employee's name.)
8. What were weather conditions like? ~:~
9. Give name and address of any witnesses: ~,¥47~'~,~
10. Did police investigate? (If so, give 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? J~P~ ~
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
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Date 11/~4/~oo~vo~oeNo. 690484
Cesaretti, Paul
2584 Glenview Circle
Dubuque, IA 52001
SERVPRO OF DUBUQUE
1044 IOWA ST.
DUBUQUE, IA 52007.
Phone # 563-584-2242
Services
JOB DATE REP SOURCE ZONE CREW CHIEF ESTIMATOR
11/10/2003
Bell
!2nsurance:Water Damage
Servpro would advise having the carpet and stairs cleaned $100.00
Qualifying Statements: The customer acknowledges that permanently discolored, faded and/or bleached areas
on carpet, upholstery, drapery or other types of material sometimes make it impossibie to restore the original
OUTSIDE TERR...
TOTAL
color or condition. Spot Removal is not guaranteed. PLEASE SEE THE ADDITIONAL TERMS AND
CONDITIONS OF SERVICE ON THE REVERSE SIDE.
I have read the Terms and Conditions of Service on the reverse
side hereof and agree to same.
(X).
Authorized Signature
I hereby acknowledge the satisfactory completion of the above-described work.
(x).
Customer Signature
29502 05/02
1 No One Home
$1 ~2.3~
TERMe OF PAYMENT: Unless otherwise specified on this invoice,
payment is due in tull upon completion of service. Interest will be
charged at the maximum allowable by law, or at 1.5% per month,
whichever is lesser, on accounts over 30 days past due.
IF PAYMENT IS NOT RECIEVED IN
30 DAYS,
THE 1.5% FINANCE CHARGE WILL
BE ASSESSED PER MONT~_____
Office - Odginal [nvoice Yellow Billing Copy Green Reporting Copy P nk - Cus omer Copy 2*d White - Trainer Back Sheet Rec~l File
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