Marlin F. Jorgensen Claim
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CLAIM AGAINST THE CITY OF DUBUQUE
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
West 13th Street, Dubuque, Iowa 52001-4864. 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: fY13Y/IH F Jor~el,?sel'1
2. Address: CZ80 Va:le~t~t. Drl've~
3 . Telephone Number: .Sg.3 - -3 ~ Lf-4
4. Date of Incident: /D-0 - )..000 cTtfd IO-/3-.J..OOO
5. Time of Incident: C{YOUIIl d nODn
6. Location of incident. (Be specific) ~gO VlCl-ekf,~e DYIV'e
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.)
D~n~J YCfyd Wa-5t~ p;ckup the ~~fy efMplo,ve-e dLlntpe-J
the 3;; .Jar, fl"<T5h *ciiftlS fJ,~"., sfr.uC!.k fh~~ iTJi7"t{sf fhe::--
tY' s /;ff/~l oft, CentS dOL'.':hL Ite Sides, *" u b~I"l~(d
dO e.J -r:o '//s Cl
8. What were weather conditions like? 7 I~ ~
9. Give name and address of any witnesses.
None
10. Did police investigate? (If so, give names of officers.)
N0
11. Was anyone injured? (If so, give name, address and extent of
injuries. )
110
12. Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
/10
13. What other damages do you claim, if any?
Ju~t The dOlA-laS-e fo it. ~ 2
3)., ..jid (!,tr/,fS,
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?
tJ/O.OO FoY" eiT~n Cal-1 ~>i- <c fvf;cl of IId-OrOO
16. Why do you claim the City of Dubuque is responsible?
fit ~r-e. [s n C> n ~ ~d. Few fit ~ c:> "lplcy~c:os to fr(!>d-
- Co
n~sc Qd"tfS the oj iTr ft,-e'f c/o. These (!~u Zt"ve...
Ru hltell- /"('(ff{d dH J <rr-~ 0 I.l (\I <I YPaYS ole!.
17. Have you made any claim against anyone else for damages as a
result of this incident? A(o
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
2000
/ t:> -I~
day of
Defob~r
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88!110 S,\ _ /\lO
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(Sign ure
/'1a'Y!t~ r JO~ietJ set{
(Print Name
9S :21 hId 91 IJO 00
(Revised January, 2000)
03/\13;J3C1
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BARRY A. LINDAHL, E
CORPORATION COUNSEL
MEMO
To:
Mayor Terrance M. Duggan
and members of the City Council
Date:
October 25, 2000
Re:
Claim of Mr. Marlin F. Jorgensen
Claimant Date of Claim Date of Loss Nature of Claim
Marlin F. Jorgensen 10/16/00 10/6/00 property damage
This is a claim for damages to two of the claimant's garbage
cans, which they sustained when they were thrown against the
garbage truck by City employees.
According to the report of Paul F. Schultz, Solid Waste
Management Supervisor, the claim is correct as filed. It is
therefore the recommendation of the Legal Department that this
claim, in the amount of $20.00, be paid by the Finance Director and
submitted to ICAP for reimbursement.
~ ~4t~/~~"~/~/ /~~~
BAL/cg
cc - Mr. Don Vogt
cc - Mr. Paul Schultz
cc - Mr. Marlin F. Jorgensen
196 CVCARE PLAZA DUl\UQUE IOWA 52001
TELE 319583-4113 FAX 319 583-1040
e-mail btalesq@mwci.net
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