Claim by Dawn RannalsClaim Form
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Page 1 of 2
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OS BAR ' 3 P~312: 19
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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This written report constitutes your Gaim against the City of Dubuque, Iowa. You should comple~tq t 's~orhr;n 4
full and attach any additional information that supports your claim. ~u~~; ~;, ~~,1
The Gaim 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 Counal. 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 y,~iether your Gaim will or will not be paid.
1. Name of Claimant: Dawn Rannals
2. Address: 2599 Pearl
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3. Telephone Number: J / c~J~Q/
4. Date of Incident: ~ 'f~ ~ "'~( >r'~
5. Time of Incident:
6. Location of Incident (Be specific): Asbury Road about 20 feet before Green Street
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11. Was anyone injured? (If so, give
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and extent of injuries.)
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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 extent of damage.)
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13. What other damages do you claim, if any?
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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.)
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' ~ ~- STORE + 2004 ~ •
4200 DODGE STREET
\~~ DUBLIQL'E, IA 52003-0000 L'S
~ (553}~82-1003
LICE IO«%A
Service Order: r (~~~~~~~~~~~'~~~~~~~~~~~~~~~~~~
See cashier for goodvear registration card or visit
_._ t~~~~~.goodvear.com to register your tires
17 a"E L ~A~IE j PHONE ~ 48571)0 24364
Eit-'.: -2ilOf 12.~ti\_-BLS, JESSICA , IA __ i (563)557-3098'•
1 ~ ~t:~KE ~10DEL COLOR
L.+ '~~" ~ C)DO~IETER CC ~TO~IER.-~RRl1 .~L TI:1IE SERVICE CO\4PLETED TI~9E
I ,+Iric-t'I-~= 12:x- Pit ?OEIR-O1-23 01:14 P~'I ~ .
__ ____ _ Se:-~ ire Description Ser~~ice
` _ .1~ Rf tt hite~catl - 1\ 0.00
- `. ;r"r 1=; ~:;•:~fe - C iE~ ICED. FT.3~ R.0 . \, 1 Tire> - Ci.~\IPLETE i3t ~T \ibL'RF~f:R?;~.-
- . alp ~ ~t.n; -fns=ai - CO\1PLETE
- ~ •r~ :: Ac~epred - \ C Tire `teunt
- .i` etc:,, Opri;atai - \O AC'Ti0\
rr '-_ , t1E 3.-tt~ti'"E 5.00
- ~la - : f Ra~wredl - C0~9PLETE
E : ! 1L i_ ~R FEE ,,;t)
- ~~ ;pc ,e of t )Ic3 Tire ,lceepted - CO\(PLETE
T?.=.A. DEPTH
4 _ .
~- ~•Ie:chn*ldise Description i Quantity ~~ Unit Price '1Ylerchandise
F ' ~ .,: R : ~ B1t' Y-TRAC 1 ~S.UO 5.00
I ~ ;'::1P I\ 1 1L VE ( I.7i 1.75
i
1~.. .... c.~„n,nt,
Total (Excluding Tax) G3.25
DISCLAIMER
I hereb~: authorize the stated repair ~rork to be done along with
the nece>sar~ material. and hereby grant It al Mart permission
^erate ,he <ehide hereto deszribzd on streets. hiehwevs or
_~_.~.thd:z for the ^urposzof testing and~or inspection. an
e~p:es; mzchanic'> lizn is hzrehy aclatowkdged on above
~ eh~ciz to .ecure the amaunt of rzpaus [hereto.
it AL-`.I aR')- 1S `OT RFSPO\SIBLE FUR LOSS OR
DAtLa.G[ TO t'F.HICLES UR aRT1CLES LEFT 1K
t EHICLES IN C-1SE OF FIRE. THEFT OR AVl"
OTHER CAUSE BF1~O~D ti'AL-MART'S CO'STROL
SIG\ED
DATE
Ql: 4L[Tl' C'U\'TRuL. TECH: 1\-ILL! a.\ i ; ~;'~
SERI It RTR GREETER. ~ T[PHES 3-3-
TIRL "f[CHXIC'I:~S. D~t'iGHT anS
Ol-?3-Z00g
____^._~^~ CC'STOViER SIGN.ATtRE DATE
H.~, ,~E -Y'cl[_R Lt'G Nt:TS RETORQUED AFTER THE FIRST 50 MILES.
• .a
l do agrez and Cully undzrstand than m•. nxan:
~~eL•idz had a lou oiI Ievzl irhen I broueP,t is !o
it al-Mart li,r an oil chance. This eas pointzd out :~~
mz. than 1 ~eillinch. rzquzstzd l1 ai-\lan to ei,angz
the oil. 1 •., il! not hold \i'a;-\lan ranonsibir tnr aa~.
dama¢e in m~ motor vehicle b~ the lo~c oit le<el
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Save MQ T
neY• live better,
WE SELL FOR LESS
MANAGER R09ERt
ST#.2004, ~ 563) 582 _HARDING
OP#.00000434,7 1003
ORQER NUMgER`E ITEMS F E# 95.7R#.05172
P205/~5R15 „ 0Q485700243b4w ' .
HP.VRLVE STM 009919877777, .~. .
IRE' b00, •...55.
7IRE,FRLANCE.06811 1 00•X
EE.. 0000031pp632... ;5.00'X
.. •, ' ~ • . rLE.ITEMS,COMPB' ,1.50'X
8T A~7E., .T
• •• ; ,TAX. 1. ,75000X,. ~• •b3.25.~
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# ITEMS Sa~D 4
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_ See cashier for good~'ear registration
ll , 1. -- --- -- ~~~~~~. oodt•ear.com 1•o re ister.'our ti
1~?..~, .-.. ''Ic'S 13:4 ,i'~:r1$.~
JESSIC.1 ~ Ia
5'E ~~- - -- -- - _~
MODEL
- (iD0\dF7 ER CL STO.tifER ARRIVAL Tl~•I
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- - - - - --=_--_------_~_ __ 30ftS_u2-3-t u3:;s P:~I
- ------ _ Service Description
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11~}tire~~all - 1V"
- `'r` Pre„ure - C'HECI:ED Ft 32 R 0
. _~
or ~•isit
4LUU DODGE STREET
DUBUQiJE, IA 5?003-0000 US ~ '
063)582-1003 ~,
LICr IO~'.~
Service Order: I~+I~~II~~ +
_-___ I ~~IIII~III~
I~~II III
PHO\ E K
(563)557-3098 485700 57376
,COLOR
i SERVICE COMPLETED TI:~fE
3003-02-3-i 03:J? PSI
Service '
Ct~ ~t' -rrltnsliall - CO.L'1PLETE - \"zn Tirzs - CO~.IPLETE DOT: patlg (1•~~
- _ old
' ~. ~ ;_I,3.; ~-i:..: - \O.=,rT!O~ - ~ C Tire Mount 0.00
- ~~ 4.Ji BAL '•vrF
~~ opted -COMPLETE
1 %r.i' Ir1 1.s0
i
_ ;~=ci'chc~ncii;e llescrip li to ~
per;, t,;Ri. BtV GTRAC
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i
Unit Price ~t7erchandise'
ss.no ss.cto
i.~s i.~s
i
_ ~ Total (Excluding Tax) ~,_ s ,
DISCLAIMER
I hereby authorize the stated repair work to be done along with
; ; the necessarc material. and h:rehy ~~nt R al-Mart {xrtnission
to "perm: the ~ ehicle hereit; described nn 3treetc, hi •
' eLseu~h2re !nr the purpose o1 testing >=ttwa;s or
axpress mrchani;:'s ~ and or inspection. An
hen is hereby acknrnvledged on abova
cc•hide to secu;a the amount of repairs the2te.
\~ AL-MART IS NOT RESPONSBI-E FOR LOSS OR
Dr1iLIAGE TO VEHICLES OR .-1RT(CLE~ LL-FT I\'
~'EHIC[.ES 7\ CASE OF FIRE, THEFT OR :1NF
OTFIER C:1USE 6E1.ONll tl'AI_-M:1RT'S CO\iROL.'
- OZ-?-~-2008
1I.'~, ` -~ ~-r)~"R Lt,G N r CLSraMER src';AruRE '
LTS RETORQUED AFTER THE FIRST 50 MILES. D~aTE
1 do a~_ree and fulh understand that m4 a,r•K,.
vehicle had a low oil level when f brought ii to
1l'al-\larr for an nil change. This was painted ou; :..
me. that l willingly requested ~Cai-\lart to dt ne.
the oil. I will not hold \t at-'Mart respomiblr tT; ,^,..
damage to nn' motor ~~ehicle by the lain oi! I, ;;,
S[GNED
DATE -~--
Qi .~[ [fl FU\TkGL fl_Cli ~I~EPNF\ 1a1?
SERV ll'R7R GftEF"(t((~ 1;.~1RI: 1.Ut
TIRE TECH\'I('IA\t GER -V ~ {„qt
WAL~M r
~A~tT
Save money. Live better.
MANA~EREROBERR NARDING
ST%,2004.OP8s000048185.TE~~90,TR8,09260
ORDER.NUM$ER~~p4$67p057376w " ~ " "
P205/65R15.,.07413170$777,,,,.,55.OO.X
HP,VALVE.STM.009919817602....,,,1,75.X
TIRE,BALANCE.068113143632......,S.OO.X
TIRE.FEE.,,.,000003700848,....,.
••••••~ .. TIE.ITEMS.COMPLETE. 1.50.7
RED.vIkES.,;; " '••SUBTOTAL.....63.25..
004136400282 F, 1.24.N
..,......TAX.1...'tS000~%AL;..,.64.43..
............... .TOTAL,. .68.92..
................CASH. TEND .80.00..
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8888,,,. DUPLICATE,RECEIPT,.,,, 88,8%
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# ITEMS SOLD 5
.,.TC8,3561.5326,$817,2686.276..,,,,
I~ I I N I I I I I I I N I I N~ I IN I I I I I I I~ I~ ~i I~
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..Rate.the",et,yelaart~com%rs{j~y$;;;;
~. ,.,..02/24/08..,..14:55:43...
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