Claim Cain, Leroy R.
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CLAIM AGAINST THE CITY OF DUBUQUE,"IOWA '1D~t(~~:!-
This written report constitutes your claim against the City of Dubuque, Iowa. You ShOUI~
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:
LEROY R. CAIN
2. Address:
3597 CRESCENT COURT, DUBUQUE, IA 52003
3. Telephone Number:
563-583-5911
4. Date of Iricident:
October 7, 2004 approximately 2 AM
5. Time of Incident:
October 7, 2004 at approximately 1:30-2:00 AM
6. Location of Incident (Be specific):
3597 CRESCENT COURT. DUBUQUE, IA 52003
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 nameo)
CITY WATER LINE BROKE AT 3953 CRESCENT COURT, DUBUQUE, IOWA AND WATER
RAN DOWN HILL INTO FRONT YARD AND THEN INTO BASEMENT.
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8. What were weather conditions like? NORMAL
9. Give name and address of any witnesses:
NEIGHBORS
10. Did police investigate? (If so, give names of officers.)
NO
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.
~ttach estimates of damages or describe basis for ascertaining extent of damage.)
CLAY AND GRAVEL ON FRONT LAWN AND MUD AND WATER IN BASEMENT.
SEE NOTE ATTACHED.
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?
i
$250.00
16. Why do you claim the City of Dubuque is responsible?
CITY WATER LINE BROKE.
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?
N!A
Dated at Dubuque, Iowa this 13th
day of
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ignature)
L e R cJ 'y ,1f, (!/J ¡/I(
(Prhlt Name)
OCTOBER
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(Rev. 1/00 & 7/01)
October 7,2004
city water line broke and got water in basement. My wife and I cleaned basement and
dried up water.
Removed furniture ITom basement, cleaned up floors, scrubbed floors. Worked ITom 2 AM
to 5 AM.
Worked rest of day, the 7th, cleaning the basement, scrubbing the floor and put furniture back.
Also, cleaned clay and gravel ITom ITont yard.
Total time 10 hours at $25.00 per hour for total of$250.00.