Claim Robinson, Elmer J.CLAIM 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: Elmer J. Robinson
2. Address: 710 Hennepin St.
`
3. Telephone Number: 582 0470
4. Date of Incident: January 18, 2005
5. Time of Incident: Approx. 5:30 A.M.
6. Location of Incident (Be specific): Sewer backup into my basement
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.)
Had a watermain break in middle of Hennepin St. Sunday night. City was called and fixed break.
Don't know if that caused the sewer backup.
8. What were weather conditions like? Very cold.
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.)
The only damaged caused was a very wet and dirty rug in basement which City people cleaned up the
best they could. The same thing happened approx. 20 years ago.
13. What other damages do you claim, if any? None but hope they check
the sewer more often. First time we had toilet paper and body waste - some mess.
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?
Nothing
16. Why do you claim the City of Dubuque is responsible?
Because they repaired the water break which probably caused the sewer to plug.
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 20th day of January, 2005. , 20 .
/s/ Elmer J. Robinson
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Iv) II iIv~
lljjl/1V1
t\(J,"1 (c
This written report constitutes your claim against the City of Dubuque, Iowa. Y~ should
complete this form in full and attach any additional information that supports your claim.
de' ,
CLAIM AGAINST THE CITY OF DUBUQUE,IOWA .
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 O~ WILL NOT BE PAID.
Y. ~ . jl .., l ~,' .,(/ ~,'
1. Name of Claimant: r;~ .cjJ<< 1/ '." , )~
2. Address: '71 (J d~~ '<4/
3. Telephone Number: 5rfJ-~117C:)
.' 1
4. Date of Incident: 6!7F::' LJ&<-YcUf::J /-f ,.let? f
) /
5. Time of Incident: (~ 3"-' ~. ;1'-" ( '. .' .,7 .'
6. Locatio,n of Incident (~~ specific): ~1U~ ,/:'?,-c ,ii1;f"
.~'lz--b /};li.// c.l)Wc~~J
I
I
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
emplp'ye~'s naY."~') 4, '/ /1 II ~ /
. ",j".;cH/ -?'?2?~ /7f..u.t"-Jr/ .-??V /J '~~P-- /7 . % 1
/ :2 ,7, w" 7 (7 /~. // /' #
. . L t.G < /Z';?-VL .' f f', ~..~
, /": . /"".J
i&~/~.-cJ;/t:~ ~~,d {:~ t4?-t-r-eJ/e~~
8. What were weath~r conditions like? I:~/ cf!g.e
/
/
9. Give name and address of any witnesse~:
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.)
/"7
// ' ci;/ } /il 'U~1 ? c'Lr y-/ /~i!:.:1
J
/t'
'YcJ
13. What other damages do you claim, if any? f} m1 f.) L..I.t i:;~ J ;~ 1
r!tY/rj( <<if! /Jg~-ey. /)')JL-1''lU>If~> J/J.;''/ ~A<'h ..I..I,.e. -&r:-V '~.1f~7\./
14. Have you been compensated for any part~r '~;::'~~y -~any~a~
company? (If so, give name and address of insurance company and amount pliiid.).
/7~
/tc)
/Zo
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 Dubl,lqu~110wa this ..t't1. Jf
;--"";';
--'
day of i704?
%{::u~} /-f;~
(/' (Signature)
84ZbJ? J /);~-~.>C'J
(Print Name)
, 20 ?1'5.
,"-,
"
_L
(Rev. 1/00 & 7/01)