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Claim by Shirley WiegandDUB uE M hMORAN DUM Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL To: Mayor Roy D. Buol and Members of the City Council DATE: April 26, 2013 RE: Claim Against the City of Dubuque by Shirley Wiegand Claimant Date of Claim Date of Loss Nature of Claim Shirley Wiegand 04/26/13 04/08/13 Property Damage This is a claim in which claimant alleges that a blocked city sewer line on Kaufmann Avenue backed up into claimant's basement. This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa Communities Assurance Pool. cc: Michael C. Van Milligen, City Manager John Klostermann, Street & Sewer Maintenance Supervisor Shirley Wiegand OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944 TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org CLAIM 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 West 13th St., Dubuque, IA 52001. It will then be referred to the appropriate department for investigation and to the City Attorney's Office. 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. \\ rr 1. Name of Claimant:. l Y1 , ri l�l�t eGcd 2. Address: 1315 v ,j 11v(- )3cr.- 3. Telephone Number .5 L 3 ` S ! 1) ._ 3 4. Date of Incident: ,j()/3 5. Time of Incident: ` ()) p ►'Yl A. Location of Incident (Be specific): 1375 Kc L.Prnc.i.r►r, !��e . , � � (-2-e, I0LA1- 1 h +lc\ (()(1_4(1._ . 7. Describe the 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.) ('`1 (l Cwt Cs(-) prn i'1c.:;T10-ed d1 > nt;t.) dc.kit4.- ,. a - _• . • i /1 h a )11-12 'h L (1-i t .1,� c t, i n L I ,a.cr. ` ►� e ! ?� (�(� 1Ot, a� + ` k4 . r' 171 ; ✓. -i�1 ? c -r? C.) 8. What were weather conditions like? 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) E I :C WJ 9Z ddti 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.) to ' (2i/t, - _ 13. What other damages do you claim, if any? Lost +5 �.L 4 a in k i1 C+ L;- ve c�.ute_ .gip -►41 L, ap^' J 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.) iii 0 H o rye_ © it e..5 i ►r) S _ tom. ti- vv o+ D 0 e. . 0 it y i.A..I q_5 ‹i -14 (AAA 15. What amount do you claim from the City of Dubuque? 16. Why do you claim the City of Dubuque is responsible? cr t_(s, .i, 4 tt e. i t9 j e r,� z ►� �D �Of- , . lay e u3 ere - f Lj ~+l1 tA) � w .. d P +We ri;t &yld +key. r' h Lor lle 1 {�"' 4 i ✓° V 1& i nn k 0, 4 c, 5fi r t "i- C w pv'4 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and 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 this day of 4f /, ; / , 20 / ,,o,Lig,,,, /4 )') ,9---------------- (Signature) 31'7 V i ,._ A ZI-) ) "' --,','L)---;-7. (Print Name) ( r--1 Rug - 6 foot long 19.98 2 rugs — 3 foot long 8.98 each =18.97 Vent brush 6,98 Cat litter 14.77 electric snowman 29.99 Step ladder 18.97 Dog food 19.88 Dust mop 7.98 Broom & dust pan 6.97 Cat food 13.96 Baby bed 170.00 Potty chair 19.98 High chair 69.98 Pack —n- play 59.,98 Power mop 19.98 Wooden shoe rack 19.98 Satin queen comforter 74.96 Queen comforter 49.96 2 campchairs in bags 17.84 Childs blow up furniture 20.00 Tupper wear 19.86 Blender 15.00 2- rubbermaid drawers 26.94 Singer sewing machine 197.00 Coleman cooler 9.98 12 — towels 35.64 16 — washcloths 16.00 Wooden dining table & chair 100.00 67 — misc. canned goods 67.50 Wrapping paper, boxes, bags 20.00 2 — twin mattress sets 450.00 2 — rocker recliners 400.00 Swivel rocker 150.00 Misc. office supplies 30.00 10 foot by 5 foot carpet 45.00 8 foot by 4 foot carpet 25.00 Christmas tree — 6ft. 60.00 Kenwood stereo 100.00 2 pair tennis shoes 40.00 3 pair boots 60.00 Wooden snowman 30.00 Labor to remove destroyed items 200.00 De- humidifier 204.00 Boot tray 4.97 Mattress pads - 2 23.92 Futon & mattress 119.86 Coffee maker 17.88 Cat litter box 17.98 Misc. home decor 30.00 3 — thermos 53.94 Cookie sheet 4.50 Muffin tin 5.96 Glass set 9.97 Cooking pot 8.94 Corel dishes 26.97 Cutting board 6.97 Water picture 2.00 Coffee mugs 17.00 Small wooden table 15.00 Entertainment center 100.00 Clothes hamper 15.97 Chicago cutlery set 60.00 CAUTION! t••• rut., may oe contannnaled ii . u nun's, overflow rrern ••, _ Rte.,. eley cheat a' • t• • I and iron/ phyeke, • 0 .• t • 0 rnev poto SOW) flak P RECAUC ION ! puede Uta, rOntanvnan4 .ieifido on SeberdarnIento teenverel Sun a!Centerfita60 esearin Pot r.vor ,.antengase shock, dot. sons evie al conlm.to •■••cr. WO puede sum**, rIes�o pars is 00406 •711 OF DURITOUF iittie reit IC; CAUTION! This area may be contaminated due to a lemporery ovedlow from a sanitary sewer. Please stay clear of the area and *void physical mint, as it may port* a h risk, RECAUCION.! Emu lima puede *star coniamineds -. deltoid° t o terriPCNINI 41e WI ikerviariitatio sainnerrio. Por1 , mairrtengese stiviado rde igt Dna y i vi1t el contact° ikeircat quit SupCorkee i n I ii ,uy: .,_.