Claim Humke, Bob & DonnaCLAIM 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: Bob and Donna Humke
2. Address: 3170 Hillcrest (Apt. #4)
`
3. Telephone Number: 563 590 1645 cell 563 590 1171
work 563 588 6393
4. Date of Incident: ?
5. Time of Incident: ?
6. Location of Incident (Be specific): Broken sewer line located middle of street within 2
feet of repaired water main.
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.)
The City broke my sewer line while repairing broken water main.
8. What were weather conditions like? Does not apply
9. Give name and address of any witnesses: Mister Rooter Employees;
Drew Cook Employees
10. Did police investigate? (If so, give names of officers.)
Does Not apply
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, Some bills attached - more bills to come including repair of sidewalk and lawn
13. What other damages do you claim, if any?
Not sure yet of total
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?
Do not yet have total
16. Why do you claim the City of Dubuque is responsible?
I have pictures and broken sewer line showing that the line was broken during repair of water main.
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 7th day of July, 2006.
Robert T. Humke, Jr aka Bob Humke
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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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.
1. Name of Claimant: ,00 (, c;;,{ () 011119 flLnI7/(~ -
2. Address: 3/70 P;//CNS j- G4tf -# Y)
3. Telephone Number n1-S'9o-/Cyr a/I s(f-S}?o-//?/
-- vJcrl( .:f"6j- :nr.r-GJ 9"3
4. Date of Incident: ?
5. Time of Incident: ?
6. Lqcation of Incident (Be specific):
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r
0-/ . S free.r
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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 empl,9yee's name.)
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ir-c /f)>'r 'F ,1"1- tne,/",
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8. What were weather conditions like?
ttJ(')~.r 'l..~t- y.;>!7
9. Give name and address of any witnesses:
jJ;e~P>- c::{"r- 0 :?f.~~:e;
10. Did police investigate? (If so, give names of officers.)
(/)"eJ IIW!- ~yvj
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.)
'I;:""e- 6//,40 ql/"c(ecP _ /1:}IIT-f.- ,i'5//-c 'to ("0...."
/fJr.lu'/J~) rr'n- aI- $"'/HO,,/I( "lvf /~u/i1
13. What other damages do you claim, if any?
No JVr~ u..-J-- 0-1 1-01-,,/
/
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.)
/Va
/J 15. What amount do you claim from the City of Dubuque?
c;(() /Vo/ y..d- h"ue.- fo~/
16. Wh do you claifTI the City of Dubuque is responsible?
vr-e.
/"lq It, .
(~nr -/-t,,_ /i~1' wqr ~,...,4;.+ .,)u;--/, r(rk .-/
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
jVt>
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 7 ti day of ::Fur ' 20 0' .
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DREW COOK & SON'S EXCAVATING
10782 TIMBER RIDGE RD.
DUBUQUE, IA 52001
(563)582-9292
Invoice
Date
Invoice #
6/6/2006
1040
Bill To
Ship To
3/'ZP
HUMKE BOB
LCREST
DUBUQUE, IOWA
52001
'3 70
HUMKE BOB
ILLCREST
DUBUQUE, IOWA
52001
P.O. Number Terms Ship
Net 15 6/6/2006
Quantity Item Code Description Price Each Amount
4 LABOR 35.00 140.00
15.07 3/4" BASESTO... 7.25 109.26
8.2 BLACK TOP 43.00 352.60
I TRUCK & TRA... 35.00 35.00
I SMOOTH DRU... 50.00 50.00
1.5% SERVICE CHARGE MONTHLY
Total $5,556.11
Balance Due $5,556.11
Phone #
563-582-9292
Page 2
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