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Claim Krohn, SharonCLAIM 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: Sharon Krohn 2. Address: 1610 Rhomberg Ave. ` 3. Telephone Number: 563 557 2326 4. Date of Incident: Monday Feb. 2 04 5. Time of Incident: Normal pickup time for this area around 7:00 AM 6. Location of Incident (Be specific): In the alley of 1610 Rhomberg Ave. 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.) Garbage can was thrown after it was emptied and tossed up against siding, one of the wheelers had punctured the new siding on my garage. I don't no the employee's name. 8. What were weather conditions like? Cold & snowy conditions 9. Give name and address of any witnesses: Gary AStgen, he lives at the same address. 10. Did police investigate? (If so, give names of officers.) No, I didn't know police could be involved in an occurrence of this natur, or I certainly would have called them. 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.) Yes, rubbish barrell with wheels on it, was thron up against garage, & damaged one piece of siding, it had ahole in it when I removed the garbage can. 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? $45.00 16. Why do you claim the City of Dubuque is responsible? Because of the carelessness of throwing the can. I have a six foot apron out in front of garage, there is plenty of room to put garrbage can back, when emptied. 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 day of 3/30/04 , 20 . I take good care of my property and I would hope everybody else would too. There was no need for this to happen. You people try to make me feel like it is my fault. Now lets see how you take care of the problem. /s/ Sharon Lee Krohn (Signature) (Print Name) (Rev. 1/00 & 7/01) . . N\ M CLAIM AGAINST THE CITY OF DUBUQU E"IOWA ~ mJ ~ ~ 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:-.Jj¡O4/'J>.J ÎþdArJ /Ipm f1 ~¿mi k A~ OAJJ.J. 3. Telephone Number: 1.1G"Q- $57d:jJ.h 4. Date of Incident: ø~~ c[Á dd Or 5. Time of Incident: 1Jfl-i.Mí'.(tJ2 Æ)~~ '1. M.f.. f) l71Ûr7A. OLL) (lA.lJÜ4«(.P 7.'lJI)A$f , - . - 6. Location of Incident (Be specific): v1,uj;l.e. ú.~'.1 I/IJ/ô Ii JitJ1?daf(JA1J' 2. Address: 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.) . ~::}T~~: ~ ~ ;f;'.~M;;: ::::./:;~ ;d~ ÚY¡'_/ir1j ?nA4~ i ,J ¡bw,1J; /J1A) ~t/Ù"~~ROdJ A/J-IÞ;JJtp... . . 8. What were weather conditions like? ð,.A.Qc, ¡OÆMN1I"J"J1C!ifr~.A) 9. Give name and address of any witnesses: .JJfl4p 44t¡i'AJ¡ ).. J IuA~.A a-;( Lfi:J.. {lfl/!(J1J'- Ci4J>f!.IJ!M'I 0/ . 1/0 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.) tJ 0.>1. IAJy(!1j~ JtÇJ/)M,.Q Apdl m!LfJe!2, UN ¿r, h tz(â 7..IJ/lm~ iíÞ °ft7/~¿L (j ) - 1 </v ~ .- vt. ~f),~.L, '"'Í r:/JA1IAJiAf,{j mJ..F'e~1'1~v2{/!t1(t/~lt )¡ültÞ:it~ //YVJ;{Á.. "'",,) ,.1 )lß¥JIJW¿i . .:flu- . rð r'Id.I-¡-'11/ C{lM . . 13. What other damages do you claim, if any? :rJÚYlL 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.) 1)n 15. What amount do you claim from the City of Dubuque? ~, 0° J -,/~-:-1õi I n ~1f.(V J { ~ £-"'1' ! iJ., ,;" fe':~ f"",J ;f;J F f ~ r¿¡<Ii h.J, ).dÞ/, ¥;d, 17. Have you made any claim ag inst anyone else for damages as a result of this incident? (If yes, give name and address.) JyJò 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 °7' . .J þ;)ø Q' ~. c.twc rH /!M/1 j(j/Ufþ¿A.J; J) OAAJ. òfv v , ÍA~ II ! V / ' ! J7 (Slgnaturef \J ~ ./vW-dY. ~ -..t1)~~ ~ {; h C1fvm 1 'f c-'~ Jffo h n w...lJuQJ j;;~, ~~ÚJ() /frO./l'Lf!.ed (P!i~\.!'f~rti~J!:~\\i\1n ~ ~~~jj;P;uw~~'""";I:. .~o (Rev. 1/00 & 7/01) V OW Ct:Ut 1A ~ " .,------~ " Donath General Construction 525 CANDLEWICK CT. . - /J DUBUQUE, IOWA 52001 /7J~.;< 7, 04 PH. 582-7117 ~ /I '>\. I!~ /t. ¿ 7 R' {/>/" j/~ ó¿ -LL ~iG. d~- !? - II~ "".A ...£/Æ --.ð .... ~ .dI ..Ð1'V. ;.("¿>.~ LI :JIJ!.....~7, 1/ flu> '.I.;, ~ on ð ~~ V (/ -Tn..f/;,..') ,L..... ¿J/",J>..:.,/", Æ£ "::""=;' """' ..:::::::!.. Á(4 r 1"( /- ¿:;f-£ . Payment due as 10 eslimate.