Claim Michel RebekkahCLAIM 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, Dubuque IA 52001
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3. Telephone Number: 563 583 1319
4. Date of Incident: November 26, 2005.
5. Time of Incident: Morning pickup
6. Location of Incident (Be specific): 1179 Walnut Alley
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.)
I did not use my garbage can for 2 weeks and on Nov. 26, my empty garbage can was taken.
8. What were weather conditions like? Clear - cold.
9. Give name and address of any witnesses: No
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.)
Property was taken
13. What other damages do you claim, if any?
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?
16. Why do you claim the City of Dubuque is responsible?
Because my can had no garbage in it at the time of pickup, so the can should of not been touched.
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 7th day of December, 2005. , 20 .
/s/ Rebekkah Michel
1st can was taken earlier in November.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA 1:5Lvc/z'r
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This written report constitutes your claim against the City of Dubuque, Iowa. You should I
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:J1 i" C f~\ lV\) CuD
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4. Date of Incident:
5. Time of Incident: mer (\ \ (\ ~
6. Location of Incident (Be specific):
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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 nameJ 'I
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8. What were weather conditions like? r i f'iAA CO I J
9. Give name and address of any witnesses: 'i [!
10. Did !1!~ce investigate? (If so, give names of officers.)
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.)
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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 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?
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16. Why do you claim the City of Dubuque is responsible?
lI;st anyone else for damages as a result of this incident?
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)
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WE, SELL FOR LESS
"ANAGER,ROBERT HARDING
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STt 200~ oPt 0000~~61 TEt 29 TRt 08039
HT 81~~19 6.2~ X
TRASH CAN 00716911828 9.67 X
T AN 007169118287 9.67 X
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FALL 2006
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065226871557
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SUBTOTAL
DR PEPPER 007800008216 F
IA DEPOSIT 00787~234595 F
SUBTOTAL
TAX I 7.000 I
TOTAL
CHECK TEND
CHANGE DUE
6.2~ X
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0.88 X
0.9~ X
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0.60 D
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59.15
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