Claim TFM Co.CLAIM AGAINST THE CITY OF DUBUQUE:-IOWA~-~/~z~-/t~'~'~ /~
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete this form in full and attach any additional irlformatiOn that supports your claim.
The ·Claim mulet-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: ~ ~ ~ C~
3. Telephone Number:
4. Date of Incident:
5. Time of lncident: [ I. : ~RfT~
6. Location of Incident (Be specific): 7 ~C~ ~:)~_ [.L~'~ ~-
7. DESCRIBE A~CIDENT 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.) ~i-~( ~L~'
8. What were weather conditions like?
9. Give name and address of any witnesses: ~?0~~ ~ Ct~ f~'d~_~)
10. D~)olice. investigate? (If soi give names of officers.)
11. Was anyone injured? (Ifso, 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 addres~~ of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque? ~ ~ ~-~ [. 407
16. Why do you claim the City of Dubuque is responsible?~[~Cl"~--~)
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
(Rev. 1/00 & 7/01)
day of~-~~~E~ , 20_~
{Signature)
(Print Name)
TEC Services
/'/'/'68 Holy Cross Road
Farley, IA 52046
(563) 744-3174
Fax: (563) 582-633~
INVOICF
SOLD TO:
TFM Co
PO Box 300
lDubuque, IA 52004-0300
INVOICE NUMBER
INVOICE DATE
PURCHASE ORDER NO,
TERMS
SALES PERSON
SHIPPED VIA
F.O.B.[
iSHIPPED TO:
759 Bluff St.
Dubuque, A
QTY DESCRIPTION
4
32911
2g Nov 03
Verbal
call. Basement flooded submerging electric water heaters.
Cleaned 3 heaters. Disconnected one heater that was destroyed. Clean
filter compartments on 2 furnaces.
11/26 Wire new water heater.
PRICE
39,50
39.50
SUBTOTAL
TAX RATE
TAX
FREIGHT
THANKYOU!
AMOUNT
39.50
197,50
0.000%
0.00t
o.ooi
$197.501
TOTA~ ]
~50 Mai~ St~e~
DUWOAN INS AND IVK~E
Nom:a~er ~;, 2003
$2,152.25
Sub-m~ah $ lSO,(g;
Ta;~ $~.~
To~l:
Thankyou for ea~g KANNDO pmfm~iomd S(mtim!
200]-1~-29 14:07
56~-588-9961 0117-CUSTOmeR SERV~C P 1/1
MEMO
Date:
Regarding:
16 December 2003
Damages to 759 Bluff St.
Summary of Claim
Internal expenses as follows:
25 Nov 03 through 3 December 03
Remove damaged items
Jim Beau, Jim Jurisic, and Richard Harry 21 hrs ~ $9.50 per hr.
Remove old water heater and install new one
Don Schrnitt 8 hrs ~ $16.00 per hr.
Parts
Rent adjustment to Tenant for no hot water
Other expenses per attached invoices
Jim Brown Hauling
Roto-Rooter
TEC Services
Lowes (water heater)
Karmdo
Total Claim
$199.50
$128.00
$ 33.0O
$ 20.00
$ 90.00
$ 13t.61
$ 197.50
$ 169.06
$2302.90
$3271.57
TFM Co
P. O. Box 300
Dubuque, IA 52004-0300
(563) 556-8050
Fax: (563) 582-6334