Claim Pauly, JeannineCLAIM 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: Jeannine Pauly
2. Address: 3150 Westmore Dr.
`
3. Telephone Number: (563) 588 9067
4. Date of Incident: 6/6/2006
5. Time of Incident: Morning garbage pickup
6. Location of Incident (Be specific): in front of house by curb
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.)
Note was left on extra garbage with stickers asking to please take it due to how fussy workers can be.
There workers three away all 3 (2 w/sticker) 40 gal. garbage cans...
8. What were weather conditions like? Normal
9. Give name and address of any witnesses:
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.)
3 Perfectly good 40 gal. cans were thrown out. Cans cost $12 each at Wal-Mart.
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? $36
16. Why do you claim the City of Dubuque is responsible? No reasonable worker should throw out 3 fine garbage canes.
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 , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
'. A'I/~~~
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA /' -;V~-l;tA
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:---<.leAI'In ;ne fo..tA. L J
2. Address: '3/ SO \.vest ""or", Df'.
3. Telephone Number( r;6 3) S<3/t - 1067
4. Date of Incident: f) Ih J'l(J06
I I
5. Time of Incident: r?n CJ rn I AJ J '" r J,?-<1P
6. Location of Incident (Be specific): In fronT
b,'r;'(::- Uf)
I
(") P. no<< Sc_
.bJ l.14rb
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.) ,zx\-rC{
f7/}-h> b,,<l~ leFt- nr. Jarb<>.ye w/ <;f-/(I\er<; astl/;'\7 +-0 fl1ecu;-e
-j-qKf> if. r/ ue 1-(} /'0<1/ ?"s~J 'A,nrkers (;"'..... Ae. IAe Wor~rrs)
fhrew fA WClJ all? (4.WI <,f,'c.-rer\ I-{o ~c.(' 9arb<tJe co.."'> .
I . ( f-~ en. hre Cq~
8. What were weather conditions like? f)"r"" Cl
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
"0
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.)
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It /1..- (/,c;. r: In. at-
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13. What other damages do you claim, if any? . n Cli"e
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? It 3 b
16. Why do you claim the City of Dubuque is responsible? (10 I'e 'lS" cJnQ b/e
f"Jt7r ke r
5hoCllrj f-I-.rtJlA/ oLAf? P/",e 5t1rh~fe O'!11 S"'
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
nC)
,
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
,20_"
(Signature)
(Print Name)
"t
(Rev. 1/00 & 7/01)
I ITEMS SOLD 9
"!!~~:!'ART'
fJ!!:!i~ICES.
HAN~NE:E~~8:ROTR LESS
( 563 HARDING
ST, 2001 OP, 0000) 582 - 1003
LIGHT BUL 1783 TE'
TRASHBAG B 001316890005 73 TR, 06702
TRASH CAN 007325700625 1 .01 X
20 BIKE 007169118052 5.91 X
TRASH CAN 008787653661 29.21 X
007169118220 19.73 X
HEDGE TRIH 0028 SUBTOTAL ~71 .62 X
87735615 .57
TAX 1 /ggJO:AL 1 :U~ X
TOTAL 10.32
CHECK TEND 157. 75
CHANGE DUE 157. 75
# ITEMS SOLD 60.00
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.H~~~I~lt"'!t:~/r:I:~la Flthlr'.
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" ''''13:55
WAL*MART'
A!.WAVS LOW PRICES.
/I}!!JF .
WE SELL FOR LESS
HANAGER ROBERT HARDING
( 563 l 582 - 1003
5T~ 200~ oPt 00003532 TE' 1 TR' 03983
5WIHWEAR 08016912 . 6 X
GW SKIRT 00237980 . 2 X
BRIEF 0090619183'/8 3 . 00 X
BRIEF 009061918371 3 . 00 X
FEH 5PRAY 001160808766 2.86 X
PRN TOt PRN 000251995860 10 . 87 X
NITETI~E 068113166512 3.06 X
TEMPO 8T 12R 003700008917 5.00 X
TRASH CAN 007169118220 11.62 X
SUBTOTAL 86.99
TAXI 7.0001 6.09
TOTAl. 93 . ~8
CHECK TEND 93.08
CHANGE DUE 0 . 00
TC' 6158 9305 7671 0399 2869
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06/16/06 16:37:08