Claim by St. Paul's Lutheran ChurchTHE CITY OF
DUB E MEMORANDUM
Masterpiece on the Mississippi
BARRY LINDAHL '~
CITY ATTORNEY
To: Mayor Roy D. Buol and
Members of the City Council
DATE: August 15, 2007
RE: Claim against the City of Dubuque by Jeff Zasada on behalf of St. Paul
Lutheran Church
Claimant Date of Claim Date of Loss Nature of Claim
St. Paul Lutheran 08/14/07 08/03/07 Property Damage
Church
This is a claim in which the claimant alleges that the floor drain at St. Paul Lutheran
Church backed up due to a blocked City main.
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
John Klostermann, Street & Sewer Maintenance Supervisor
St. Paul Lutheran Church
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
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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 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: ..~T~ ,~~~ ~ ~~~Gliv~ ~~t~+f'Cf-j
2. Address: o~C7 0~~ 1~[ KS cZ'71 ~~~
3. Telephone Number ~Co .3 - ss~
4. Date of Incident: Q~ ~ 3 a
5. Time of Incident:
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
10. Did police investigate? (If so, give names of officers.)
8. What were weather conditions like? ~= r~ ~
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9. Give name and address of any witnesses: C; ~r
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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.) " ~
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13. What other damages do you claim, if any?
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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.)
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15. What amount do you cla' from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
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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.) ~D
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 ~S ~ , 20~
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AGREE TO PAV REASONABLE ATTtSRNEY FEES, COLLECTION FEES AND COURT COSTS IN THE EVENT OF LEGAL ACTION PURSUANT TO COLLECTION OF AMOUNT DUE. X ~~
I DO HEREBY STATE THAT THE ABOVE WORK HAS BEEN DONE IN A WORKMANLIKE MANNER AND TO APPLICABLE CODES.
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