Claim Rettenmeier, MikeCLAIM 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 V. Rettenmeier
2. Address: 2458 Beacon Hill Dr.
`
3. Telephone Number: 588 3668
4. Date of Incident: 7 18 04
5. Time of Incident: 9:40 A.M.
6. Location of Incident (Be specific):
On Fremont Ave. @ Marion St. - westbound lane.
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.)
Riding my new bike w.b. on Fremont when a (Marian St. - Location of Excavation) my rear tires struck and edge of the street asphalt surface that was exposed as the sandstone filler had worn away exposing the Edge
which punctured my tire and inner tube.
8. What were weather conditions like?
Sunny
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).
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.)
See attached Receipt - Tire & Inner Tube Punctured.
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?
$25.93
16. Why do you claim the City of Dubuque is responsible?
A hole had been dug and filled with sandstone. The Sandstone washed or wore away exposing jagged edge of asphalt surface.
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 22nd day of July, 2004.
/s/ Michael Rettenmeier
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
It
t~~?l¡eé'{(":~
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.
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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:
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2. Address:
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3. Telephone Number: S cf,9. 3 (, J'
5. Time of Incident:
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4. Date of Incident:
6. Location of Incident (Be specific):
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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.) . .
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8. What were weather conditions like? fY1 Y Itcfd.." "L :r¡v /'" ~¡¿ ''-'l (¡'£.
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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).
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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.)
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13. What other damages do you claim, if any?
þ"()A'£
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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.)
,4r 0
15. What amount do you claim from the City of Dubuque? -JI d .c" '13
16. Why do you claim the City of Dubuque is responsible? A ;),"L~ ~ !?£$jV
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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,
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
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(Signature)
J1l ( ~ )M a f.5 -¡J£ IV ".d. ~
(Print Name)
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(Rev. 1/00 &7/01)
THE BIKE SHACK
3250 Dodge St.
Dubuque IA 52003
~MW. theb i keshack. com
(563) 582'-4381
2393
flike Rettenmeier
2458 Beacon Hi 11
Dubuque IA 52003
(563) 588-3668
TICKET 36598
DENNY 07/19/20041:06p
AOO0891381 ZR 5.0 REO BOcm
[ìT ROAD
----'-."-.----.-."'-"---"-"---..-.,----... ...-
Employee Not Found
1 Tire or tube relaced Q/R ".vI<
1 700 X 23-25c PV TUBE 4.94
1 700 X 23C CoNlI SPORT 1000 15.29
vlith either Q/R or ,¡heel off bike.
Keep your bike safe and ready to ¡-ide
with regular maintainance.
Est Comp: 07/19/2004
---. ."......----..-..------.......---.-
Subtota 1
Sa les Tax
Iota 1
Rcvd
Check 10052
Bike Repairs done right by expert
mechanics!
I illlllllill 11111 111II 11111 III! !III
24.2:3
1..70
25.93
25.33
25.33