Claim Lanham, Linda & Zachary
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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 COP)I of that report and recommendati on.
The final decision on all clams 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: l\l\c\at. L.. c1- ZC{c.h:t~~ D LctnhurY\
2. Address: d.-3 i d, ~QSQd~f\c. .0('. l1ntt 7,+. Du.}y{ffl{f :Iowc.{...
3. Telephone Numbe r : 5(p3 551 Qo17
4. Date of Incident: OAJ 1'J~ tlD .c.c ~ .s 0 p-t I::' d.oOlc
5. Time of Inci dent: I\N~o ... .S .p ^'I
6. Location of Incident (Be specific):
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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
employeeDs name.)
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8. What were weather condi ti ons 1 i ke? Ai A
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9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
NA-
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? -fo~s'18'-r- \Ala. It
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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
11
15. What amount do you claim from the City of Dubuque? toqd-..&,cS
16. why do you claim the City of Dubuque is responsible?
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FLOOR S,H.OWGOMPANIE$
1475 Associates Drive - Dubuque, Iowa 52002 - Phone:(319) 557-9952 - Fax: (319) 557-9988
QUOTE
Zack Lanham
3380 Dana Drive #8
Dubuque, Iowa
52002
Home Phone
Cell Phone
Date
Salesperson
'1-l0'0(,
John Seier
2312 Pasadena Drive Unit 74
DESCRIPTION TOTAL.
In smalllibrarylfam room, we propose to:
1) move furniture $45.00
2\ remove existina camet and Dad and haul awav 127.5 sf $0.26 $33.15
3) provide new carpet, similar quality 127.5 sf $2.59 $330.22
14) provide new pad 127.5 sf $0.90 $114.84
5) install new carpet 127.5 sf $0.81 $103.28
6\ remove wet tac strio $15.00
7) additional trip to allow concrete floor to dry $20,00
axes $31.16
Floor Show Com nies TOTAL $692.65
pa
propose hereby to fumlSh malenal & labor complete m accordance with _ -~~- fo
s..........._uuns r the amount of :
Acceptance of Proposal. The _ prices specific.;oliuns and conditions '
is authorized to do the work as spacified, """"""'nce must be S"'ned -r:.,re satisfact, .ory and are hereby accepted, Floor Show Companies
the r1ght t Wilhd ~ ' proposa IS void after 30 days Floor Show Campan'
o raw the Proposal at anytime, for any reason, under any circu~tance, .... reserves
Date of Acceptance _ I _ I _ Signature
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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.)
1JO
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated thi s ot!
day of --4,.J/i-nA4-
, 20~.
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