Claim by Jerome Ehlerst • ~f
BU UE ~~WA
CLAIM AGAINST THE CITY OF DU Q ,
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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1. Name of Claimant: t~ ~R o~F
2. Address: ~ J~=~~~~~~s~`c~r,C,~ ~/ .
3. Telephone Number ~'~~,~~ ~~ ~ ~ J ~~~
4. Date of Incident:
5. Time of Incident: ~-aB~~/ ~ ,~~3 ~~ t~~
6. Location of Incident (Be specific):
th employee's name.) ,
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8. What were weather conditions lik
9. Give name and ad ress of any witnesses: ,Q
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10. Did police investigate? (If so, i e-riay~~s of officers.)
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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
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
13. What other damages do you claim, if any?
14. H u een pensate r all of your claim by any
insurance company? (If so, give name and address of insurance company and
amount paid.) ~,~Q
15. What:amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, gi~~ me 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?
Dated this _`~,~ day of
(Sig~fure)
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(Print Name
20~
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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
t~os~ ago-o ~ vts
t ~ ' '1-800-556-6168
Fax: (563) 556-4680
.. , email: kanndoincdbgCa3aol.com
website: www.kanndoinc.com
950 MAIN STREET -DUBUQUE, IA 52001
CARPET CLEANING
Room Size Sq. Ft. Amount
KITCHEN
DINING
LIVING
HALL
STEPS
BEDROOM
BEDROOM
BEDROOM
BEDROOM
FAMILY
BASEMENT
^ Vacuum to remove embedded soil from carpet fibers
^ Apply pre-spray and deodorizer to loosen dirt from fiber
^ Steam clean w/RX20 rotary steam extractor
^ Groom carpets to set pile for efficient and uniform appearance
^ Heat Transfer
^ Treat spots as needed
^ Move and block up furniture as needed
^ Carpet fans !eft
CARPET CLEANING _
CARPET PROTECTOR
CARPET CLEANING & PROTECTOR TOTAL
UPHOLSTERY CLEANING
FABRIC PROTECTOR
CLEANING UPHOLSTERY & PROTECTOR TOTAL
AIR DUCT CLEANING
^ Remove registers and hand wipe
^ Air wash all ductwork
^ Wipe dawn interior & exterior of furnace
^ Re-install registers ~ ~,~ p~ ~~ r
WATER HEATER
DRYER VENT TOTAL
AIR DUCT CLEANING TOTAL
SANITIZED TOTAL
AIR DUCT & SANITIZED TOTAL
NO TAX ON AIR DUCT CLEANING
_ _
Clien t Name:~E=~ ~~ E ~ !~ -G,~-~
Billing Address: , % ~ I S ~-u N_5 vv f ~ !<
City l~ ~f'~l-1 V E State ~ Zip ~ ~ ~'
Job Phone:_~ ~ 3 '" ~ ~~ ~ ~ Other Phone:
Contact: Phone:
Job Address
City State Zip
E-mail Address: I
Cleaning Date: 5 ~ t ZI D ~ Estimate:
^ Cash ^ MasterCard #
^ Check ^ VISA Expires
Total amount due upon completion of services. A finance charge of 1.5 % which is
annual percentage rate of 18%, wi0 be charged on the amount of this invoice starting
days after the invoice date.
OTHER
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KANNDO Professional Services wants to serve you better. Please read ti
following consumer awareness information and initial it.
When was the last time your carpet was cleaned?
How was it cleaned?
Alert technicians of liquid spills because we may have to use a prose:
to prevent wickiog.
Carpet Cleaning
Please move small items, knick knacks, antiques, breakables, etc.
For ideal drying conditions: set your thermostat at 72', use fans and
dehumidifiers, especially in basements.
Please leave blocks or plastic sheets under furniture for 24 hours or until dr
The KANNDO method of cleaning carpets will deodorize & sanitize
your carpet.
We cannot repair worn fibers through cleaning.
Cleaning will not repair color bss due to fading, chemical damage, pet stain
or any other permanent stains or color changes due to BHT, and / or
foreign materials embedded in carpet that may wick up and cause red,
blue, green, yelbw, etc. spots.
Upholstery Cleaning
Due to the unpredictable nature of upholstery fabrics and dyes, KANNDO
makes no representations or warranties regarding the upholstery
cleaning to be performed.
.. .-
..-
By initialing where indicated below, the client acknowledges that
client assumes aq risk associated with the cleaning and hereby
releases KANNDO from any and all loss, damage, or expense sustained
by Gient as a result of the leaning.
Payment due upon completion of the job. THANK YOU!
~ ~~ St>t~ ~ ttS6'Fi ii ~o o~ c ui w ~iu:c i uarciv~u i.vi iiNii~i,°ci ~.a~ y
Blue File Folder ^
Thank you for calling KANNDO Professional Services!!!
SUB TOTAL ~-~~ ~ t1c~
TAX '
GRAND TOTAL ~ c7S. u C~
UPHOLSTERY CLEANING