Claim Blong, ShirleyCLAIM 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: Shirley Blong
2. Address: 411 Lowell St.
3. Telephone Number: 556 8278
4. Date of Incident: 12-10-01 - 12-11-01
5. Time of Incident: Sometime during the night and next day.
6. Location of Incident (Be specific):
Basement laundry room and overflowed to next room.
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.)
Sewer backup into the laundry room and adjoining room. I called Roto Rooter & they called City Maint. The blockage out in the Street caused
a huge amount of back up - it just gushed out into the basement.
8. What were weather conditions like? Mild
9. Give name and address of any witnesses: Steve Howard, Daryl Horkeimer, Roto Rooter Svc. 552 1826
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
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.)
Items I must have replaced... Enclosed Estimates for carpet for room next to Laundry Room.ruined from the overflow and tracking through. Estimate from K-Mart for items below. Also had to replace playpen.
13. What other damages do you claim, if any?
Replacement of the following (2) Lg Trash Cans - $10.56 Ea, Wood Laundry Rack $10.00; Playpen $60.00; Broom ($9.00) and Dustpan $1.50
Mop $12.00
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?
$1000.00 for damaged items, cleaning supplies and Roto Rooter bill, plus hours of cleaning up this mess.
16. Why do you claim the City of Dubuque is responsible?
Because the two Roto Rooter Employees and two City Sewer Maintenance Employees said sewer back up was caused from the Sewer Blockage outside & City Maint. (Mr. Gooch) said the
City was at fault.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa this 4 day of February , 2002.
/s/ Shirley Blong
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
c,^ M ^ A ,sT T.E Or DUBUOUE. OW^
This written report constitutes~]~r claim against the City of Dubuque, Iowa. You should
complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13~ St., Dubuque, IA 52001.
It will then be referred by the City Council to the appropriate department for investigation.
Once that investigation is completed, a report and recommendation will be submitted to the
City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE
OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: ~__?~//~.~// /.?/--~A/~--~
2. Address: Z/// /__~,~//_2~-/_¥~ oC7z' '
3. Telephone Number:
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City employee was involved, give the
employee's name.)
I
8. What were weather conditions like? .~ ~ b~~
9. Give name and address of any witnesses: ~- - ~ ~ Sr,..~5-;-/~A$
10. Did police investigate? (If so, give ~mes 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 prope~j and the extent of damages.
Attach estimates of damages or~_.describe ba.~_sis for ascertaining extent of damage.)
13. What other damages do you claim, if any? d~:~--::~---~ :F'~- ~'~
14. Hav~ ~ou been compensated ~or an~ pa~ or all of your claim b~ an~ insuranae
company? (If so, ~iw name and address o~ in~uranc~ compan~ and amount ~aid.)
15. What amount do you claim from the City of Dubuque? /dD0~" ,~,t' ~/'~'~-~-~
16. Why do you claim the City of Dubuque is responsible? ?~-<m-~$
,' t /
(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 ~ day of /~&.
(Rev. 1/00 & 7/01)
¥I ~. ~,c, ,.<nC
~aignature)
/(Print Name)
, 20:~ .
TARGET
02/05/02 9:42 RM
RETURN BEFORE 05/06/02
IIIIIIIIIIIIIIIIIllllllll IIIIIIIIIIII
GIVING R GIFT? Include a gift receipt!
R receipt dated within 90 da~ is
required For ali returns & exchanBeb,
002 053100891 EUDY T 2.50
003 053100815 CARD T 4.50
004 05~110029 CRR~5 T 6.50
005 05~I00690 CARD T 2,95
006 053101485 EVD¥ CARD T 3,85
SUSTQTRL 80.29
T: 6.000% TAX 4,82
18TAL 85.11
OHECK PAYMENT 85.11
RECEiPI ID~ 2-2036-008G-0080-0741-2
UOD~ ~1216240 CSH~ 404 6 ITEMS
Save ALL Receipf~
Give GiFt ReceipT5 & GJFfCard5
Ask about Receipt Lookup
i .CARPET ONE
587 UNIVERSITY AVENUE
DUBUQUE, IA, 52001
563-557-7212
FAX 563- 584-2086
www. carpetone.com
l ESTIMATE FOR
I Blong, Shirley
411 Lowell st_
1 Dubuque, IA 52001
1563-55~8278
Estimate
ESTIMATE NO. DATE
648 12/27/01
AREA DESCRIPTION QUANTITY PRICE TOTAL
Lower le.. [ Bk CARPET, PAD, LAB.. allowance carpet .. 27' 0" SQUARE YARDS 15.95 430.65
INSCPT:T/O-CPTON.. PERYARD 27.00 YARDSLABOR 2.50 67.50
INS CPT: SPECIAL wrap waits 2,00 EACH 20:00 40.00
INS CPT; STAIR~fN 4 steps, wrap one. 1.00 EACH 40.00 40.00
INS: SPECIAL QUOTE move furniture 1.00 EACH 50.00 50.00
SUBTOTAl. 628.15
TAX 0.00
~3,~ .,~,,,~,~ i~ o~,,-/~w ;~3 ~ Tri! ~,tv ~;t~ vcatr [ TOTAl- 628.15
approval, Please sign and return
SIGNATURE