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Claim by Carissa Young~~ CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ~l 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//w~~i??ll not be paid. 1. Name of Claimant: Carissa Young 2. Address: 2757 University Ave. 3. Telephone Number ~ ~ 3 ° 5 ~ ~ - ~ ~ S~ 4. Date of Incident: ~ ~ ~ 0~0~ 5. Time of Incident: ~ }~ ~ ~ ~= ~© ~ 6. Location of Incident (Be specific): Cedar Cross Road by (gas company) 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.) H \ ~ S ~icn ~ (ay-s~tc~ L~ ~ ~- nv Ctc `~~~ C~ ~-+` ~,~~ C~ -~- Pr~7-, -~-4~ L~ CS'a i- ~ ~ a~~. C`~-z E -t- 8. What were weather conditions like? ~ V ~ C~-S i -- Ly ~ ~ 9. Give name and address of any witnesses: C CTy P~~~ ~e U~ t= - can, ~-' 10. Did police investigate? (If so, give names of officers.) A- C~3 Y ~~~_~~~tit~ ~--1 U >=~ i c t2 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). N o ~~ 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.) rp, 13. What other damages do you claim, if any? O N ~ `'~ ~Y'x~ .! E. 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 o3nt~do you claim from the City of Dubuque? w 16. Why do you claim the City of Dubuque is responsible? Yl ~ ,~ C.[7A3 ~ Cj I y ~ ~Rr/ ~ ~ c7 U S ~ L5 ~, -1 .. ~ ~ STS C~ ~-S - V'n1 C~.! ~ ~'Dh~ ~~. 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) N~ 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? l' ~ Dated this '7 ~ day of ~-~~ Cam- , ?~ ~ g~ ~,I ,L._7~~1~"ttl(~ (Signature) ' E S ~ I ~d S - d~~l 80 C~?.t'! (Print Name) Q~%\;~~j~~ ~'~~~,+`~~~e 3450 Center Grove Dr. ^ + 6 ~ PO Box 933 Dubuque IA 52003 (563) 556-3281 ~, ~ . ~.: (800) 776-3281 ~ i ~ Page ~~IL 1 - - - --- -- Carissa Young ~A/R Number: _ ~ Invoice Number - - -- - ~, 1275 Prairie Du Chien Rd customer Number 1o25ss _ _ 164238_ --- - ', Dubuque, IA 52003 PO Number: Printed. 02%05%2008 5:04 PM -- - Phone H :563 Phone- - Auth Number: _ Copy # 1 ;Phone (C): ( ) Phone Oth: (563) I Service Writer: 248 Date Opened: FEB 4 08 O ( ) Year/Make/Model: 2001 Honda Civic i Estimate Amount_ $ i Date Notified_ FEB 4 08 VIN: 2HGES2674 1 H530518 _ _ Tyrpms & Conditions: ~ Date Delivered: '~, License Number: ~ T e of Sale: - - -- --- -- -- -_l ' Stock Number: SM762A Mileage In: 116095 Customer Tag Number: Mileage Out: 116095 i Signature p - _ _ ---- -- - - - ---- _ _- - - - _ _..- _Qty T Total -- _ -- -- ', Descri tion Hrs or ' List ~ Ext Grand Total '~ 7. Customer statement of problem Customer States RAN OVER SEVERAL BIG CHUNKS OF ROAD-CHECK FOR DAMAGE. 7 -- Correction/Action Taken 'I ROAD TEST AND DIAGNOSE HOWL NOISE 1os ' II NEEDS LR WHEEL BEARING AND HUB ASSEMBLY 'I NEEDS LR TIRE-BROKEN BELT ~wbT~l J 1 2. Customer statement of problem check wheel alignment & print specifications ', CHKALIGN - ' 1 -- Correction/Action Taken '~ BOTH REAR TOE SETTINGS OUT OF ADJUSTMENT 1os SttbTotal Jc~b # 2 3. Customer statement of problem ' mount & balance 1 tire MB1 - 1 -- Correction/Action Taken 108 Part Number Failed Description TIRE DISPOSAL DT00048474C0 P185/6515 CONTIPROCONTACT 86H AWROADHA... P185/6515 CONTIPROCONTACT 86H Sub Total Parts ' ~t ~ 3 4. Customer statement of problem Customer States REPLACED LR WHEEL BEARING HUB ASSEMBLY 1 -- Correction/Action Taken 40.OOli 40.00 i I i I 19.95 19.951 16.25 1 I 2.25:; 2.25 1 72.45 72.45' I, 1 5.00 '~ 5.00' 79.70 1----- ~-----~ ~ 95.95 , ', 72.00 108 ~i>t~~,~~~~~ 345DCenterGroveDr. ~ i t PO Box 933 Dubuque IA 520D3 (363) 536-3281 (8D0) 776-32$1 "~~`'~'` CarISSa YOUrIg - _ _ - i_A/R Number: 1275 Prairie Du Chien Rd I customer Number: 1o259s Dubuque, IA 52003 PO Number: Phone (H): (563) Phone (~M: (563) Auth Number: Phone (C): Phone Oth: (563) Service Writer: 248 Year/Make/Model: 2001 Honda Civic Estimate Amount $ --- vIN: 2HGES2674 1H530518 Terms & Conditions: License Number. __ 'Type of Sale: Stock Number: SM762A Mileage In: 116095 ~ Customer Tag Number: Mileage Out : 116095 Signature __ - Description - _- Part Number Failed Description 42200-S5A-008 BEARING Sub Total Parts ~lub'~btaP Job # 4 Miscellaneous Charges and Deductions For All Jobs - --- - Misc. Shop Supplies iar~e~?ill$ P i e ~ Invoice Number ~, - - - 164238 '~ Printed: 02/05/2008 5:04 PM Copy # 1 __ _ Date Opened: FEB 4 08 Date Dehvlered: FEB 4 08 - -- t ._ --- _ I _-, _ _ _ - _ -_ _- Hrs or List Ext Grand Qty Total Total ' 1 88.62 ~ 88.62' 88.621' - -- ~ - -- 160.62: i _ ' _ __~ -.. _ 10.00 1 ~ -- -. Total Labor i 148.20 Total Parts 168.32 Total Sublet 0.00' ~ Misc. Chrgs 10.00 I Car Rental 0.00 ' Freight 0.00 _-- -- -- --~ Deductible 0.00 ' Special Tax 0.00 ~ Haz Mat Chrg 0.00 ~~ Sales Tax 22.86 ~~. !-_~~~ 349.38