Claim by Melissa GilstrapTRACEY STECKLEIN
PARALEGAL
M FMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: December 11, 2013
RE: Claim Against the City of Dubuque by Melissa Gilstrap
Claimant Date of Claim Date of Loss Nature of Claim
Melissa Gilstrap 12/10/13 11/27/13 Property Damage
This is a claim in which claimant alleges that her refuse can was damaged during
regular refuse pickup.
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
Don Vogt, Public Works Director
Melissa Gilstrap
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
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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 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.
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2. Address: 1CoccI S r ' C. P\ Sa
3. Telephone Number: {-m S[)3 - S11
1. Name of Claimant: mQ1°,,c-)0A_
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4. Date of Incident: 1 \UV ache
5. Time of Incident: MO(' O(' (�� ►'1 "oC -tf)l t— \-Cj CtM
6. Location of Incident (Be specific): C Q r' (A C, Vi= (1
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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.)
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8. What were weather conditions like? A (
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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.)
13. What other damages do you claim, if any?
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.)
15. What amount do you claim from the City of Dubuque?
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15, Why do you claim the City of Dubuque is responsible?
te_c_cuu,or_ 3oci 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 at Dubuque, Iowa this C: day of DPL� , 201.
C`(1 Q ox p
(Rev. 7/12)
(Signature)
(Print Name)
741EISEN g7T
62r ,,a1900 Dodge Street
563/557-8222
PROD ID QTY UM PRICE TOTAL
TREAT,DOG SOFT ASSORTED PER POUND
CAN,GARBAGE 30 GAL SHEET STEEL --
550631 1 EA 19.99 19.99
FU0 ,II: LAMB SMA 1 ES ND��^-�--
13401447 1 EA 29.98 29.99
CANDY,PEANUT BRITTLE 6 OZ
58818843 1 EA 2.99 2.89 n
GUM,EXTRA POLAR ICE SLIM-PAK
9070138 1 PK 1.29 1.29
8UM,EXTRANINTERERBHSGRFREE10 PK
75170938 2 EA 1.29 2.58
ORINK^NONSTER LO CARD ENERGY 16 OZ
74040025 1 PK 1.98 1.99
DEPO8IT,SINGLE .05
21 1 EA .05 ` .05 n
DRINK,PEACE TEA ASST FLAVORS 23-0
53634689 2 EA .83 1.98
SUBTOTAL 64.45
Tax 61.41 U 7.000% = 4.30
7% Sales Tax 4.30
TOTAL 68.75
Mastercard (Debit) 08.75
XXXXXxXXXXXX3830 (Approved)
MELISSA GILSTRAP
06/13 16:29:08 001 ' 39921682001
1 ThelB8O'8 Yd-VeV--o'Dm8r
INVOICE #: 5956245 WSID: 7ND8NO1
924041007'2833'488b1C7C'5[805F08320C
8284TC2.33.5V5O TILL ID: 17
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Confidential
This communication and any attachments may contain information which is confidential
and privileged by law and is for the use of the designated recipient. If you are not the
intended recipient, you are hereby notified that you have received this communication in
error, and that any review, disclosure, dissemination, distribution or copying of its contents
is prohibited. Please notify City of Dubuque immediately by telephone at (563)- 589 -4120 of
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical /Health Information
3) Personnel /Disciplinary Information
4) Bank Account Information
5) Financial Information
6) Credit Card Numbers
If any documentation you desire to submit to the City of Dubuque contains any of the items above
this cover sheet must be attached directly to the confidential information and indicate the type of
information that is included.
1, QI3 . GASA -t- ,9
include the following protected information:
, hereby certify that the attached documents
Social Security Number(s)
Medical /Health Information
Personnel /Disciplinary Information
Bank Account Information
Financial Information
Credit Card Number(s)
I understand that this information may be distributed within the City organization or to agents of the
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
CI)
Date