Claim Michel, RebekkaCLAIM 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: Rebekkah Michel
2. Address: 1179 Walnut St., Dubuque IA 52001
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3. Telephone Number: 563 583 1319 or 589 5843
4. Date of Incident: 10 13 05
5. Time of Incident: pickup time - I notice at 4:00 P.M. when I got off work
6. Location of Incident (Be specific): Backyard allie - 1179 Walnut
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.)
My garbage can was taken because it was broken. The can was originally broken by the garbage man.
8. What were weather conditions like? Normal
9. Give name and address of any witnesses: no witness
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.)
Yes, my garbage can was thrown around and broken then it was taken
13. What other damages do you claim, if any?
I have the wrong lids for my cans - I got the neighbors, but don't know which neighbor's lids.
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? Price of both garbage cans
16. Why do you claim the City of Dubuque is responsible? They broke the cans & took one.
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 25 day of October, 2005.
/s/ Rebekkah Michel
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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This written report constitutes your claim against the City of D!JbUcrue; IQW8. You should
complete this form in full and attach any additional information that supports your claim.
CLAIM AGAINST THE CITY OF DUBUQUE,IOWA
The Claim must be filed with the City Clerk at City Hall, 50 W: b1h 'St., 'DtJbuque, IA 52001.
It will then be referred by the City Council to the appropriat~~~E!partment f()r)nvestigation.
Once that investigation is completed, a report and recommencr~i()n will be~mitted to the
City Council. You will be provided with a copy of that report andrecornmendation.
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.
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
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employee's name.)
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8. What were weather conditions like?
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9. Give name and address of any witnesses: i.\()
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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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12. Was any damage done to property? (If so, describe property and the extent of damages.
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14. Have you been compensated ror 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? ~\ ,C$l
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16. Why do you claim the City of Dubuque is responsible? +h,l,,_l"J
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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?
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Dated at Dubuque, Iowa this ~ S
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(Rev. 1/00 & 7/01)
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