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Claim Blocklinger, MarkCLAIM 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: Mark Blocklinger 2. Address: 3089 Kane :Ct., Dubuque, IA 52001 ` 3. Telephone Number: 563 582 2337 4. Date of Incident: Thursday, Oct. 6, 2005 5. Time of Incident: 5:30 A.M. 6. Location of Incident (Be specific): JFK Road & Stoneman Rd. 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.) Drove over a huge bump on JFK Road made of reclaim blacktop. It washed out causing big potholes causing my truck to bottom out and damaging it. 8. What were weather conditions like? Dark & cloudy. 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) No 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.) Damaged by lower engine block heater hose by putting a hole in it causing my truck to lose coolant and over heat. Without use of truck for 2 days. 13. What other damages do you claim, if any? New hose, hose clamps and coolant. No visible motor damage. 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? $45.00 to cover cost of new parts, labor and running to get parts. 16. Why do you claim the City of Dubuque is responsible? Poor excavation made out of wrong material causing it to wash away. Spoke to John Klostermann - Bill Meyers fixed the problem right away. 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 13th day of October , 2005. /s/ Mark Blockinger (Signature) (Print Name) (Rev. 1/00 & 7/01) , ) . . , ~/zrv' CLAIM AGAINST THE CITY OF DUBUQUE, lOWA ~~J~ / ~1-A{ L}f]~ '/' L. U J.'f...~1 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: ~c::..'\~ ~\~l:::..\J.,\\l;\~.ex 2. Address: ~\)~<\ \-\~~~ \2.\... - ~\}...~\>-.~I..e.. \~V\ S~\X)\ 3. Telephone Number: S\o~. S ~~. ~~:')" 4. Date of Incident: '"\.. ~u. ~ SD. C).. 'I , C) ~\... \:, '~.S:~'\:) S \ . , 5. Time of Incident: S '. ~ \) '\\. ~\', 6. Location of Incident (Be specific): ~ Y "" ~I:)':)I:). ~ S\a~~~\J..~ %. 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 ~Ployee's name.) \. ' ,()>.{e., c:y'{~\ '().. \\\..l..~€- ~U~'\l (}~ ~'\-~ ~Do.& ~\Ac\e.. C\\ \~~\C).,\~ ~\\}..~\\\()~~\ ~~S"-w. C)\.l..\ ~Cl\.>..S;\~~ ~\~ ~D-\\'\()\~c;. ~~\).S\ \\~ ~~, ~'\.).~~ \c:> ~c:>~\~\'r-. Ou.\\).,~c:'}. c\()..~a..~\ ~ \.t, 8. What were weather conditions like? (\C\" ~ ,'" I.:. \a\)..6.~ \ 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). \\C:::> 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.) \J~ ~C>..~~ ~'\ \t'-\-.N~( ~~\,,~ ~\~~\i.. ~~().\~ ""~S e.. ~\ ~\\\,,~ ~ ~el\e.. \ \\\\- ~~\)..S\\\..~ ~"\ \'\\A~\<. \0 \DSe.. ~~el\Ci~~ ~~o. C)~U \--.e...o,:\, \JX~\()'-'.)." \}.Se.. ()~ \\I..>.~\J., ~a, ~C\~\S, 13. What other damages do you claim, if any? ~v'\\l \\~<;,e.." ""elSe. Q.\Ci\'\'\.\lS ~~c\. ~I::lC \ C>..~\-. \.Ja \l \ S\:l..~e. ~C)\C), 6.\)..~a.. '3e.. , 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.) \\.a 15, What amount do you claim from the City of Dubuque? ~ "-\ s .~a \ C) ~a,e-\ ~ cS~ I::l~ "e....~ 'YC>.."~S \ \l0..~()<: ~N~ 'U\\\\,~~ -\ a ~cl 'V~dS, 16. Why do you claim the City of Dubuque is responslble?'Xoc:>, ~'\~'\~\" 0\'\ ~G.c.e... ~\)..)." ~~ 'N\C\'.~ ~l0..\tA'Q\ ~\i.\)"S\""~\\ \e::. ~l0..<:-,~~\0a..,\, S"o\\.e,.,\-t::> -.so"~ ~\CS~~Q~~ - ~,\\ ~~tlS \c\\~~ .~~ ~\D\)\~\\.~\ 17. Have you made any claim against anyone else for damages as a result of this Inc~nt~'\ . (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? . ~., . .-~' \~ dayof \:)1.:.' I:)~QA ,20(.)<;. //kIz- ~~ (Signature) \'S\ 10..<: \<.. ~C)~"" \ \ ~ ~ ~ (Print Name) Dated a~Dubl.lAUe, Iowa this I' (Rev. 1/00 & 7/01) ~ . Advancel':-:" AUtDParts/~ '\Vc're ready in Advance, Store # 06<128 (!:,63) 585-2'J 38 3190 Centrol Avenue Dubuque IA 52001 10/07/2005 18017 10 REG 02 Cash l E'r': Dou3 B. I1EH QTY PRICE TOTAL 1081303 1 $6, ~~ $6 ,1~ II XflCI) mUIFREEZ<: CClOLA 12016 /881303 1 $6,~1 $6,14 II XflC,) fiNl'lFREEZF CClOLA 1,'016 'iO'1~.8H'1 2 $0,68 $1 ,36 HOSf CUiHP #10 5210 1,192951 4 $1.~'8 $5.12 HiJSE HUllli 5/8' BY fHE 1726301509 Sub Total $19.36 J"dX @ 'r, 00% $1 . 36 fohl $20.7'Z Cdsh Pa"~I~fmt $?(J. 72 Ston tu RETURN tte~s illllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll111111111111 *X717930027028* . hdllSClct ion #7028 I'HElPT ',[QUIRED FOR RETURNS WAfIRANTY HJFCllmATlON flVAIEABLE Vi., l 1 IJS a't Www. odVim(:eCiutorar.ts. C:O!'1 CUSTOMER COpy ,.