Claim by Ken & Billie RolwesBARRY A. LINDAHL,
CITY ATTORNEY
MEMO
To: Mayor Roy D. Buol and
Members of the City Council
DATE: April 17, 2007
RE: Claim against the City of Dubuque by Ken & Billie Rolwes
Claimant Date of Claim Date of Loss Nature of Claim
Ken & Billie Rolwes 04/12/07 04/07/07 Property Damage
This is a claim in which the claimants allege that the basement of their residence
located at 155 Stoltz Street sustained water damage due a broken water pipe.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
BAL:tIs
cc: Michael C. Van Milligen, City Manager
Jeanne Schneider, City Clerk
Bob Green, Water Department Manager
Ken & Billie Rolwes
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 balesq@cityofdubuque.org
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:
2. Address: ~5
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3. Telephone Number ~`~ Q' - a a ~ '~--
4. Date of Incident: ~ - ~ - O '7
5. Time of Incident: ~ ~~ 0--~, ~ /"~
6. Location of Incident (Be specific):
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8. What were weather conditions like? C') °
9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.) CD o
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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 employee's name.) _ ~9,,,~
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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 end address of insurance company and
amount paid.)
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15. What amount do you claim from the City of Dubuque?
6. 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, 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?
Dated this day of , 20
(Signature)
(Print Name)
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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MTZ-DUBUQUE CENTRAL Store 3508
1000 IOUJA ST
DUBUQUE IA 52001
(563)583-5719
Fax (563} 583-2538
www.mautzpaint.com
SALE 11:19am
Tran # 9956-0 04/12/07
E10/14669 10
JEREMY
Order # OE0017479A3508
ROLWES*KENNY
Account 9260-5513-8
Job 1 ROLWES*KENNY
Bill To:
ROLWES*KENNY
155 SiOLiZ
DUBUQUE, IA 52001
859-0978 3011008 EACH 3011008
INSLTHANE HI GLS WHT
*Sale Price 1.00 @ 52.49 52.49
Discount (X20.00) -10.50
Color: Custo~ MANUAL
8~4 844__ OZ 32 64 128
YO Yellow Ox - 36 - -
BU Burnt Umbr - 28 - -
RO Red Ox - 2 - -
Custom Manual Formula Match
Cauents: Coupon w20
MRNL'AL
Sl18TOTAL 41.99
7.000X SALES TAX:1-165200100 2.94
CHECK# 7913 -44.93
TOTAL $44.93
Returns cannot be vracessed far 10 days or until the
check clears your bank.
-------- Thank You ---------
receipt rec~li red for refund
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