Claim Rans, JesseCLAIM 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: Jesse Rans
2. Address: 113 N. Booth
`
3. Telephone Number: 563 557 1033
4. Date of Incident: Jan 8th 2006
5. Time of Incident: 5:00 A.M.
6. Location of Incident (Be specific): 2076 Chaney Rd.
Front Door
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.)
Police Officer rammed the front door open. Putting a hole
in door and destroying jamb and trim. They had a warrant for a Biscuit. Nobody knows or
has heard of him.
8. What were weather conditions like? 30 degrees
9. Give name and address of any witnesses:
Carlos Bell, 2076 Chaney Rd.
10. Did police investigate? (If so, give names of officers.)
Police did investigate - names are unknown.
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, the front door has a hole in it. I have attached estimates and pictures of the damages.
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? $259.00
16. Why do you claim the City of Dubuque is responsible? They broke the door. All they had to do was knock and they would have been
let in.
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 10th day of January, 2006. , 20 .
/s/ Jesse Rans
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUB~QUE, IOWA Dji/'l/i.(I /.1/7 ~
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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: '" .5?t ,1 t/ tI15
2. Address: {17 /II /~/?dl0 !:,t
3. Telephone Number: ..50 J 5 S 7 / 0 J.3
4. Date of Incident: J"l,^ <61-111;) D IN 0
5. Time of Incident: S.' () i) A,IV)
6. Location of Incident (Be specific): 6/D) to c ~aV1tJ Ad
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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
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8. What were weather conditions like? ~ .1 ()
9. Give name and address of any witnesses: CM I"s ~ II
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10. Did eolice investigate? (If so, tve 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.-
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? A0vvL
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?
$ :;) s-1, {) ()
16. Why do you claim the City of Dubuque is responsible? '1t-u11 b/79/1.t hu. d (Jo,r"
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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.) 1110
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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 am~!1g_________________ '__
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Dated at Dubuque, Iowa this _ day of
J~ vi lA-AI} , 20 tOto.
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(Signature)
Je .sSe. ~q1l/'>
(Print Name)
(Rev. 1/00 & 7/01)