Claim Shadler, Roger JCLAIM 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: Roger J. Schadler
2. Address: 898 Spires Drive
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3. Telephone Number: 563 583 4508
4. Date of Incident: 8 31 2005
5. Time of Incident: 8:00 A.M.
6. Location of Incident (Be specific): 898 Spires Drive, Curbside, Refuse collection
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.)
Removed & emptied 35 Gal. Fiber Drum and didn't return the container to Curb.
8. What were weather conditions like? Normal
9. Give name and address of any witnesses: I talked tosupervisor (Dave Sitzman)
and he has informed by emploee that the container has not returned and to file a claim.
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. Attach estimates of damages or describe basis for ascertaining extent of damage.)
Loss of 35 Gal Fiber Drum
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?
$36.45 Submit Invoice on the cost of replacement
16. Why do you claim the City of Dubuque is responsible?
Loss of property
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 31 day of August, 2005.
/s/ Roger J. Schadler
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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.)
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13. What other damages do you claim, if any? //t)~e
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.)
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15. What amount do you claim from the City of Dubuque? yI:"3 t;" ~
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16. Why do you claim the City of Dubuque is responsible? -Lt>..!::S 8-f //,opC'y"?y
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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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
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(Rev. 1/00 & 7/01)
Oniida Air S~stems - Store: Invoice
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Invoice
Order #883333
Date: 08/31/2005 10:37:01 Eastern Daylight Time
Thank you for your order. Please keep this invoice for your records. **PLEASE NOTE**
NEW YORK STATE SALES TAX WILL BE ADDED TO YOUR ORDER AT THE TIME OF
SHIPMENT BASED ON STATE REQUIREMENTS FOR ALL NEW YORK STATE
RESIDENTS
898 Spires Dr
Dubuque, IA 52001-3190
US
Bill To:
Name:
Email Address:
Phone Number:
Fax Number:
Company:
Address:
Roger Schadler
shadesvw@yahoo.com
563-583-4508
Ship To:
Name:
Email Address:
Phone Number:
Fax Number:
Company:
Address:
Roger Schadler
shadesvw@yahoo.com
563-583-4508
898 Spires Dr
Dubuque, IA 52001-3190
US
Code Product
SDS350000 "DRUM FIBER 35 GAL [22"" D)"
Quantity
1
Price/Ea. Total
$27.95 $27.95
Shipping: Ground: $8.50
Sales Tax: $0.00
Total: $36.45
Have questions? Need Help? Call us at 800-732-4065
Email usat:info@oneida-air.com
**PLEASE NOTE** NEW YORK STATE SALES TAX WILL BE ADDED TO YOUR ORDER
AT THE TIME OF SHIPMENT BASED ON STATE REQUIREMENTS FOR ALL NEW YORK
STATE RESIDENTS
Copyright 2005, Oneida Air Systems, Inc.
.
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