Claim Heim, JeanCLAIM 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: Jean Heim
2. Address: 12606 JF Kennedy Rd.
3. Telephone Number: 583 3045
4. Date of Incident: Sept. 13, 2006
5. Time of Incident: 4:10 P.M. - 5:00 P.M.
6. Location of Incident (Be specific): On JFK Rd., Between my place to
JFK Rd. - Econo Foods.
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.)
I noticed paint on my both left tires. Paint on the bottom ofthe car. From the front tire to the back tire.
8. What were weather conditions like?
Good condition
9. Give name and address of any witnesses:
Just my husband, when I got home from Econo Foods. And my
next door neighbor saw it later. Larry Schault.
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
This Car is a 2000 Chevy Venture. The Only car that we have almost new. And
it had belong to my inlaws that passed away March 2003 & Feb 2004.
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.)
No
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?
Just $32.10 that Ihad Simoniz Car Wash clean it off. I don't want any more money,just the cleaning cost.
16. Why do you claim the City of Dubuque is responsible?
Between I got the paint on the car. If the street - If goingto EconoFoods
from my house on JFK Rd.
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?
I didn't have time to clean til now.
Dated at Dubuque, Iowa this 3rd day of October, 2006. , 20 .
/s/ Jean Heim
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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.
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5. Time of Incident:
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7. Describe the accident or occurrence that caused injury or damaoe. (Give full
details upon which you base your claim. If a City employee was involved, give
the employee' name.) Le' \
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8. What were weather conditions like?
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10.'Did police investigate? (If so, give names of ofRcers.) ~
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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
e~~ damage.)
13. What oth~damageS do you claim, if any?
Oy"\.z- _
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.)~O
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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.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
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Dated this :3 day of fJe';-'-
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(Print Name)
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SIMONIZ EXPRESS DETAIL & RECONDITIONING
3199 University Ave' Dubuque,lA. 52001. (563)583-6416
License Plate Number:
Name: d-L:..._
Address:
City:
State:
Phone Number: ( )
Vehicle Year: ~ ~
Vehicle Make: . ~
Vehicle Model: / .J__~_,
Date: /~ - ,-:;'-0(...
'.
Please Do Not Write Below This Line
Exterior Services
Simoniz Express Wax
Exterior Compound & Wax
.~
Interior Services
Carpet Shampoo
Upholstery Shampoo
Fabric Protectant
Leather Conditioning
Oversize Charges
Other Charges
$19.99
$19.99
$29.99
$29.99
$
$
$39.99
s
Clay Process
Black Trim & Tire RevitaIizer
Vinyl Top Dressing
Tar Removal
Exterior Hand Wash
Oversize Charge
_ Other Charges
$
$9.99
$19.99
$
$
$
$
Additional charges apply to oversize vehicles and
when the condition of the vehicle warrants it
Detail Packages
Complete Detail
Ultimate Interior
Bumper to Bumper
Oversize Charge
~ Other Charge~ L2~
Technician Remarks
$
$
$
$
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