Claim Seymour, Jill R.
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CLAIM AGAINST THE CITY OF DUBUQUE,"'IOW A
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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.
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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: .~ \ 'R. S-e y (Yl 0 l.{ r
2. Address: 10;5 (2/ar/u bY'. b8Q J;4 SCHJ71/
3. Telephone Number: (5~3) 58() ~- / ;).,3(p
4. Date of Incident: t - 5- () 5
5. Time of Incident: 00/ 0
6. location of Incident (Be specific): -715 ('ja rice.. b r.
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? S-tnr m-I y~ I 1J.. )\VI cl.IJ
9. Give name and address of any witnesses: LA n !LnOw 1'\.
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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~. Was any damage done to property? (If so, describe property and the extent of damages.
ltach estimates of damages or describe basis for ascertaining extent of damage.)
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~. What other damages do you claim, if any? /'J 0 ru....
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t Have you been compensated for any part or all of your claim by any insurance
)mpany? (If so, give name and address of insurance company and amount paid.)
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). What amount do you claim from the City of Dubuque?
1/ &50.9'-/
5. Why do you claim the City of Dubuque is responsible? '+-k .+r--e P i.lt J {j 5
C.i~ryt).~y -rcr
~. Have you made any claim against anyone else for damages as a result of this incident?
yes, give name and address.) N
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If the answer to Question 17 is yes, have you received any payment from that source,
j if so, in what amount?
;ted at Dubuque, Iowa this
/ 3' fu day of \ /'is
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(Print Name)
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*******
INVOICE *******
. BIECHlER
:c- 7762 Wildnest Lane · Dubuque, lA 52003
ELECTRIC, INC, (563) 583-5366 . Fax (563) 556-4466
SEYMORE! JILL
795 CLARKE DR.
DUBUQUE
INVOICE NUMBER:
0011781-IN
INVOICE DATE: 06/10/05
CUSTOMER NO: SEYMORJ
JOB NUMBER: SEYJIOl
IA 52001
PAGE:
1
TERMS: NET 30 (INT-l.5% MO, 18% YR)
JOB DESC: 6/5 - STORM DAMAGE
~~-;;~~-----~~;~----~~~;~~~;~;~-------------~;~------;~;--------------~;~;
------------------------------------------------------------------------------
3R-8400L
0-00106
10-23350
2-17562
7-01256
7-01906
7-15664
6-10302
5-30022
1-06132
~-11042
~-14039
-&TRCK
-00000
0.0
12.0
45.0
10.0
1.0
3.0
1.0
3.0
1.0
1.0
1.0
1.0
1.0
1.0
SUNDAY LABOR
0.000 Y 342.00
Labor SUBTOTAL:
2-GRC GALV RIGID CONDUIT
1-STR-THHN-BLK-500FT-REEL
TEKHW122 DOTTIE HEX HEAD
1256 BRDGPORT 2-IN CLMP ENT CP
1906 2IN 2 HOLE STRA
664-DC2 BRDGPORT 1-1/4 2SCR SE
WR189 BLKBRN 2/0 TO 1 H TAP CO
SW-2BB BLKBRN SCR TYPE SVC WIR
33PLUS-SUPER-3/4X66F
A7517 MILB 2-IN UNIT HUB
U7040-XL-TG-KK MILB 200A 4MTR
Material
TOOL & TRUCK CHARGE
Y 89.06
Y 57.00
Y 2.28
Y 11. 22
Y 2.11
Y 1.97
Y 2.15
Y 5.63
Y 4.66
Y 6.30
Y 54.57
SUBTOTAL:
15.000 Y 15.00
Equipment SUBTOTAL:
SECURE PERMIT
Y 32.00
Permit SUBTOTAL:
REPAIR STORM DAMAGE 06/05/05.
LABR&EQUIP-TAX:
MATERIAL-NOTAX:
SALES TAX:
TOTAL INVOICE:
342.00
236.95
15.00
32.00
357.00
268.95
24.99
-------------
-------------
650.94