Claim Sanford, Linda L. SanfordCLAIM 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: Linda L. Sanford
2. Address: 10351 St. Joseph Dr., Dubuque, IA 52003
3. Telephone Number: 319 588 2193
4. Date of Incident: Friday 02 02 01
5. Time of Incident: 6:45 A.M>
6. Location of Incident (Be specific): Locust Street Ramp - Locust Street Entrance
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.)
Used Monthly card - gate opened. I proceeeded into ramp. Gate came down breaking off radio antenna on right rear quarter panel.
8. What were weather conditions like? - 10 degrees clear
9. Give name and address of any witnesses: N/A
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.)
Radio antenna was broken off - (from right rear quarter panel) Assembly needs to be removed and replaced.
13. What other damages do you claim, if any?
No
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?
$174.85 see estimate
16. Why do you claim the City of Dubuque is responsible?
I believe the parking ramp gate malfunctioned. I've been parking in that ramp for years so know how to get into the ramp.
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?
N/a
Dated at Dubuque, Iowa this 03 day of February, 2001.
/s/ Linda L. Sanford
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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 Street, Dubuque, Iowa 52001-4864. 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 reco~,mendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL.
NO EMPLOYEE OF THE CITY OF DUBUQUE HAS T~ AUTHORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO Wh.:'l'n=R YOUR CLAIM WILL OR WILL NOT BE
PAID.
4. Date of Incident:
5. Time of Incident:
7. DESCRIBE ACCIDENT OR OCcuF~RENCE THAT CAUSED INJURY OR DAMAGE.
(Give full details u~n which you base your claim. If a City
employee was involved, give the employee's name.)
8. What were weather condJions like?~/-- fO
9. Give name and address of any witnesses.
10.
11.
Did police investigate?
Was anyone injured?
injuries. )
(If so, give n~me,
(If so, give names of officers~)
a~ss ~d extent o~
12. Was any damage done to property?
13.
(If so, describe property
and the extent of damage. Attach estimates Of damages or
describe basis for ascertaining extent of d~unage.)
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 ~nou~t do you claim from the City of Dubuque?
16. Why do you claim the City of DubUque is responsible?
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
2001.
(Signature)
(Print Name)
(Revised January, 2000)
Date: 21 2/01 08:37 AM
Estimate ID: 3460
Estimate Version: 0
. Preliminary
Profile ID: Mitchell
Riley's Olds-Mazda-Subaru
4455 Dodge St. Dubuque, IA 52003
(319) 608-2326
Fax: (3t9) 588-9286
Tax ID: 42-0957277
Damage Assessed By: KEITH KNIPPER
Deductible: UNKNOWN
Insured: LINDA SANFORD
Address: 10351 ST JOES DR DBQ. IA 52003
Telephone: Home Phone: (3t9) 588-2193
Description: 1996 Mazda 626 LX
Body Style: 4D Sed
VIN: IYVGE22C4S5411288
Options: AUTOMATIC TRANSMISSION
Mitchell Service: 917~163
Line Entry Labor Line Item
Item Number Type Operation Description
I 700452 BDY REMOVE/REPLACE
Drive Train: 2.0L Inj 4 Cyl 4A
QUARTERANTENNA ASSEMBLY
Part Type/
Part Number
0
Dollar Labor
Amount Units
140.95 0.6
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals
Body 0.6 40.00 0.00 0.00 24.00 T
Taxable Labor 24.00
Labor Tax ~ 6.000 % 1.44
Labor Summary 0.6
25.44
iii. Additional Costs Amount
Total Additional Costs 0.00
it. Part Replacement Summary
Taxable parts
Sales Tax
Total Replacement Parts Amount
IV. Adjustments
Customer Responsibility
L Total Labor:
0. Total Replacement Parts:
18. Total Additional Costs:
Gross Total:
6.000%
Amount
140.95
8.46
149.41
Amount
0.00
25,44
149.41
0.00
174.85
ESTIMATE RECALL NUMBER: 212101 08:34:19 3460
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