Claim Shannon, Kenneth & ShirleyCLAIM 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: Kenneth W. Shannon & Shirley M. Shannon
2. Address: 1695 Hickson Ave., Dubuque, IA 52001
`
3. Telephone Number: 563 583 0084
4. Date of Incident: Nov. 20, 2005
5. Time of Incident: 8:00 P.M.
6. Location of Incident (Be specific): 2594 Pearl St. Dubuque IA
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.)
Water in basement drain backed up caused by blockage in sewer line in the street.
8. What were weather conditions like?
9. Give name and address of any witnesses:
Cindy Latham, 2594 Pearl St., Dubuque IA 52001
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.)
Sewage backed up from the drain causing standing sewage water covering about 1/2 of the basement.
Cost for diagnosis by plumber and cost of cleanup was $147.30
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? $147.30
16. Why do you claim the City of Dubuque is responsible? The blockage in the sewer line was in the
street several house.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name anNod address.)
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa this 12th day of December, 2005. , 20 .
/s/ Shirley M. Shannon
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Or! , ' !/! 1/ jl~
b1l/~~
.~/"
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete this form in full and attach any additional information that supports your claim.
..
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001.
It will then be referred by the City Council to the appropriate department for investigation.
Once that investigation is completed, a report and recommendation will be submitted to the
City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE
OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: ke.nne-tJ1 /;1) SJ1annon y ,,-c;h'4'/~ /YI SAo.nnoh
2. Address: 1/"qS Hickson Ave, Duhil~IIP, ..TA 5.;200/
3. Telephone Number: (..5(,,3) SJj 3-00$ l/
4. Date of Incident:
AI () If 02CJ. .;200:";
5. Time of Incident:
;?OO D Ih .
,
6. Location of Incident(Be specific): rdsq y ~n,' I ,'\1- Dn hurt (If', LA
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.)
If. ) a::rl/l . J..-n) --!;rrul II /YYI II ,,y; r. d /<11 ~ hi ) .J>-f} A' k J d . " ,.0')
('AJJ...(J (J/I) jHf Jl-I.M'J>..rA.~ ~ .<liJj,lMJAJ ~ o,~ .-at"
Ll2Ji {).LL '
8. What were weather conditions like?
9. Give name and address of any witnesses: (}./ll 1/./ ~ /;I! mA /J /Yr -' , .25 q <-j
if
"iJ Jl /\.L- "J(;C. ..zs:Lu~ ,I ..J. a-u /7l ) 5~o 0 I
10. Did police investigate? (If so, give names of officers.)
./l?-D
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.) ,
::iu.u-1J.4:1.)~.kPd..J --lAp) ~~ ~-'~) ('AJI4-1/l1:"r
l Lr:l-~j ~ ,(J {I j j H1. <;f.--eJ_-U.JI1.-Cuv (' fi1 M h -' ~ /J./.f-/J-U_L I / ~ CJj-
A::/z..e ~ALLrr71 /vd~.. (' AUJ r ~-i;LA-O_;4.- ~ .f<J _/./1 /YJ1.b~
D--7LtLJ ~ 0/-- ~-~ >t '-17. 3 Q.
13. What other dama~s do you claim, if any? rJ () n -p
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?
-11/'-1/, -3 ()
16. Why do you claim the City of Dubuque is responsible? CYJd.P) J;.} ft1')y/J~.u
A~-->>u.., .0 {I/,(J--tAJJ~ -IAJ"11.<J) ....i--ru ~ b'f./LPJ...:C
,() RAJ.-P /\ ,,(J .#./ .~ I"" P...u '
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 /~ day of ;0 0 -N..-rn /UA)
,2005.
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