Claim Smith, George & ColleenCLAIM 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: George W. - Colleen Smith
2. Address: 722 Ramona St.
`
3. Telephone Number: 582 3890
4. Date of Incident: 4-20-06
5. Time of Incident: Between 3 PM to 3:15 P.M.
6. Location of Incident (Be specific): Privte alley behind 722 Ramona St. and first left turn off Adeline St. - dead end 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.)
Minibus came down alley behind 722 Ramona - saw it was a dead end and backed up into our driveway - the bus was too wide for driveway
and backed into treee and across alley and tore up some of McCormick lawn.
8. What were weather conditions like? Sunny
9. Give name and address of any witnesses: Lela McCormick 583 9892, 725 Loretta Ct.
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.)
A 10 year old - 8 Ft. tall, perfectly proportioned evergreem tree was uprooted and knocked on its side...the Bus Driver
drove off.
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?
$650.00 + $200
16. Why do you claim the City of Dubuque is responsible?
A City owned minibus damaged our property and drove off without
notifying us.
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 April, 2006.
/s/ George W. Smith
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
,0//A ~-/~/ ,
CLAIM AGAINST THE CITY OF DUBUQUE;~IOWA/' "0,' ~"'/ )
.7/ (7' t".-<////!./
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.
P ,
1. Name of Claimant: (it tJ f2. 6-E 01 ,- ~, / / r f' Il/ ~ /Y7 / r if
2. Address:/ O? ,<2 j? jilt/C ilIA S~)'
3. Telephone Number: bY;Z - 3 ,p 9 ;j
,
4. Date of Incident: f - ~O ~ (j &.:,
) 0 JS-
5. Time of Incident:AE 7' tl F,f" /t/ ~ r/J1 ,/,,1 ,,:3 LJ/n '
. f
6. Location of Incident (Be specific):;?? //ArE I-? lIE 1- /Ie>' H/ /1/( :/:;< ~ ~d/l1ad/.-;J..5;.
ffM:!-hj<,' /f'J-r 71{!? A/ d/ 4/F J/,U", <;r -k/-lc{ Eye( /)//E~/
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
eillloyee's}jlame.) . /J
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j) A~4/';f J:/\;;( y 31(,;f:Fc/ 11 /,//T# /Jd.f ,-:f;,J.:,!t:? ,;)/1'1- 'il/.E ellS I()r!I
'100 Lt) let F-ftJR dl( i ,J<; It),.g'.1 0/-' /3/7rOc-f //1./7 d ./7?;:,-r + It-/&?SS' /'J//Hl
tTNc.P -ToRr tvf). Sd/;Y)~ O-P- /J?,f~)I2/i7IS:)<' /.q4//v~
8. What we'l'e weatHel' conditions like? 5U A/ N&, c;:- CL /~/r/"&
9. Give name and address of any witnesses: /.;.!'-k /1).f(?b RtIj /~ K,
~Kj~9g-f~ 7r2"~ LO~CT/O (!r:
. 1 .~ ,
10. Did policE}.-investigate? (If so, give names of officers.)
!lid
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
/i/~
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.)
/} /0 '/ tAIL o/cl r g 6.,--- %1// lJ6clFcr/t P/;(~tJo I!,T/I')'//./~;/'
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EtlrcXji?frlJ rk' Z:;P uh7S L-V;&ofccl y:: l'~L'rFd vA::/' / rs -S:rc/ b'>
f#.E. {ius dl.-, Ju:. rJ.€.CiLf2 off,
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? ~.5CJ
~
-I- ~OcJ
16. Why do you claim the City of Dubuque is responsible? If W~1 ow' /l/""c G( "
'"
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OfT' It/I:!#' ",or /~// /nJ tiS' ,
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) l r:. '
(VO
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 Dubuq~~']owa this
I :' '~
day of 7 R... ;/
,20~.
(Signature)
&c:>K5&- It/. J~ /'/#"
(Print Name)
(Rev. 1/00 & 7/01)
1. NAME C !//U2.JE, J. LiD<J:
.
2 . DOB "-/ - ~, - </0
3. HOME ADDRESS .if ~I tt/;,,,,/ h I/Jd4~ D.. tu. flL# / J:oW/r
4. DRIVERS LICENSE # 7(,1:1Yo II,",
5. HOME PHONE I ,')~~ 3 - 5'"YS- - 1121../
6. DATE AND TIME OF ACCIDENT '1- J.tJ - ob
7. DESCRIPTION OF ACCIDENT J ~ ~-~ - kJ
~~,j -JA~ -7 ~,J t/j t/:.;~
Jiru.jJ' /J9~ J)J-~j)<J~C<.;~,
8. BUS K :z.5~ 5 t:L.L;'" ~
9. BUS VINK," -
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Splendid Valley Nursery
14973 Rte. 20
Peosta, IA 52068
5 Miles West of Dubuque
563-557-8325
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tD
2677 HALES MILL ROAD
ASBURY, IOWA 52002
.
PHONE: 563-583-926
FAX: 563-585-0614
www.wagnernurserydbq.com
AMOUNT
UNIT
PRICE
~..:
L
OESCRIPTION
c
,!II
"1'
Name
Address
Phone
CTY.
Tota
Date
Price
RECEIVED BY:
~
Location of Nursery"
Turn North at Asbury
Sold To:
Address:
City:
Phone No.:
SOlD BY ICHARGEI PLANT
SUB TOTAL
TAX
TOTAL
NVOICE
FROM THIS
PLEASE PAY
GUARANTEE NO CASH REFUNDS
~ny material failing to grow within one year, will be replaced at one half the cost provided we are
informed within one year. Plants guaranteed only until winter are: Perennials, Roses, Groundcovers,
Rhododendrons, Azaleas, and Red Maples. Returns must be accompanied with sales slip. Guarantee
will be void if full payment is not made. Also damage from misuse of herbicide by owner and lawn
care services, animal, man or act of God, or plants in above.ground planters. Only one replacement
of each plant will be made. No guarantee on sod or annuals-materials planted by Wagner's will be
replanted at the original labor charge.
A service charge of 2% per month automatically charged after 30 days from above invoice date,
unless otherwise agreed upon. Minimum 75ft.