Claim Fairchild, Daniel & Boxleiter, Teresa
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CLAIM AGAINST THE CITY OF DUBUaUE,"IOW~ jA(~~t. " )
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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 referreu by the City Council to the appropriate department for investigation.
Once that ilwestigation is completed, a report and recommendation will be submitted to the
City Council. Yc~~ 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 Clrl OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO
YOU AS T'i WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Na~eofClaimant: DaM (el1U;t[h~/d /'rp(P5t1 f)ox (e ;tpr
2. Address: r-;;(26' wa 7 -f S -I- r f? p-+ 'D u hu tAR. I A C;) ao I
3. Telephone Number: St-:iJ 6' 3 - / 15 G
4. Date of Incident: }Ct 1'\ f.,( eft y d '3 ( d ( ~ l) \) )
5. Time of Incident:~,") pr~ x'1 mate Iy 10 ,IV A M
6. Location of Incident (Be specific): 1"h ../.- ~e .s+rfJe+ ,in. --{iro~ + '0 f' v it r
k'JU5t ..:2 367 l/Ve7'-+ 5'ftee+
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
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9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.) V; X , L
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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.)
'iN ({f Lp d ,jt!.v t1y (} tti15 Cf It d d e pD '7) te J t7ti;(d
yard", 'T)Pf<~(t-(ld W4"~ fir [4'\ C2)Ur b<<iO h1tiJ{
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13. What other damages do you claim, if any?
14. Have you been compensated for any part or all of your claim by any insilrance
company? (If so, give name and address of insurance company and amount paid.)
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15. What amount do you claim from the City of Dubuque? ,DB.o '0
16. Why do you claim the City of Dubuque is responsible? Tlvt ~,j? it Y t11 a/' y...
t- 461+ kJi-c 1:::(.. 'k.--ti 'j cl +y pro per -Iy.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) ~(Q",
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18. If th~ answer to,: q.uestion 17 is yes, have you received any payment from that source,
and if SQ'j in wl!at amount?
Datect~t D~B~que, f6wa this '2 U
day of -:J to..L
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(Signature)
UOl1le / r::a/rch; Id
(Print Name)
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(Rev. 1/00 & 7/01)
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KLUCK CONSTRUCTION INC
14285 HWY 20 WEST
PO BOX 1045
DUBUQUE,IA 52004-1045
To:
Thersa Boxleiter
2367 West St.
Dubuque, IA 52001
Job Location:
Invoice 10: 93943
Invoice Date: 02-15-2005
Draw 10:
Customer 10: BOXL01
Ship Via: FedEx
Item
Description
2/15/0 Remove and rake dirt from front yard
washed in by a broken water main,
Price Quoted
Unit of
Units Measure
DATE DUE: 03-15-2005
Unit Price
Amount Billed
Retainage Held
Amount Due
Amount
300.00
$300.00
$300.00