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Claim Foley, David & Robin 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 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. 1. Name of Claimant: 2. Address: =-~ 3. Telephone Number: 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. 4. Date of Incident: 5. Time of Incident: 6. Location of Incident (Be specific): / 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 emp_Loyee's name.) _ 8. What were weather conditions like? N~---~,'~/-- 9. Give name and address of any witnesses: ~,,'l~.,~t~ 10. Did ,olice in_vestigate? (If so,.give names 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 property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) 13. 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 amount do you claim from the City of Dubuque? 16. Why do you claim the City of Dubuque is responsible? 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) MO 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 ' ~9"~q/ dayof /~t/.~- , 20 <~-~ (Signature) ~ /~"q*f'//~;?' ~ N~ (Print (Rev. 1/00 & 7/01) April 1, 2002 Thomas D. Felderman 550 8th Avenue Dubuque IA 52001 Re: Claim Against the City of Dubuque Dear Mr. Felderman: If you wish to file a claim against the City of Dubuque for damages to your client's vehicle, I would request that you fill out the enclosed claim form and return it to me. I will retain your Report of Accident and Claim and attach it to the complaint form when it is received. Once the claim has been stamped in it will be forwarded to the Legal Department for investigation. Enclosed is an addressed envelope for your convenience. Sincerely, o-/ Jeanne F. Schneider City Clerk - CC: Legal Department Mark Munson, Transit Manager Service People Integrity Resparm'oflity Innovation Teamwork I G168.33 field, 3.94 Printed in U.S.A. REPORT OF ACCIDENT AND CLAIM COMPLETE FRONT ONLY ❑ COMPLETE FRONT AND BACK DATE OF ACCIDENT PLACE OF ACCIDENT CAR YOU DROVE REGISTERED OWNER FRONT (Year) TIME ? s r STREET{$] YEAR 7 MAKE FOR OFFICE USE ONLY CLAIM NO. A.M. P.M. DARK ❑ LIGHT CIR' f BODY STYLE 20©5'" D,4-cw ,7? (PLEASE PAINT) ADDRESS 3 STATE ZIP CODE LIC. PLATE NO35 7.4 (} & STATE v216 7//L6 5 Di ,3TA 23 STREET HOME PHONE -S57 /9 2- WORK PHONE EMPLOYER l ,may/ ' •%�/r �' ' ADDRESS y f (PLEASE PRINT) STREET DRIVEN BY HOME PHONE i cif 9.2 WORK PHONE DRIVER'S .1 f/7 DRIVERS AGE / DATE OF BIRTH DRIVER'S LICENSE NO. HAS ANY PART OF YOUR DAMAGE YES BEEN PAID BY YOUR COMPANY? ❑ AMOUNT $ WAS DRIVER ON ANY YFs MISSION FOR OWNER OF CAR? ❑ EMPLOYER ZJP CC E „447- d X-.-t' CITY Ak STATE ZIP CDE �Pa&b IF YES, EXPLAIN WHAT PART OF YOUR CAR WAS DAMAGED? 1224. „cove. HAVE REPAIRS VEs Na BEEN MADE? ❑ ❑ NAME OF YOUR INSURANCE CO NAME OF / if AGENT'S_. V AGENT'" %,/y PHONE NO IF CAR NOT DRIVEABLE, WHERE CAN IT BE SEEN, KIND OF INSURANCE !JAR ON YOUR CAR OTHER CAR YEAI6/ IX/ c2e, ME�D-_ -_PyAY�- PiP COMP LL MAKE 1 . REGISTEREDOl F t/Gr- DRIVEN BY (PLEASE PRINT] • {?LEASE PI 4T) POLICY NO NAME OF AGENT C THE ACCIDENT AMOUNT OF DEDUCTIBLE POLICY NUMBER -0,414/- / BODY 19/1,5 STYLE HAS ACCIDENT BEEN REPORTED Ivd TO YOUR COMPANY? ❑ LIC. PLATE NO. & STATE >� ADDRESS .g.-0 40/3 r3T-f de-Mr4 i �7 57REPT f GTV FL r/ZIPCODS ADDRESS rl`�fp5r/ //t "I' !d STREET CITY STATE ZP COO, OWNER/DRIVER HOME PHONE WHAT PART OF OTHER CAR WAS DAMAGED? OWNER/DRIVER. WORK PHONE STATE BRIEFLY HOW n ACCIDENT HAPPENEL7 /Z '•sSiO, SZ/1' Al � WERE POLICE CALLED? WAS ANYONE INJURED? NATURE OF INJURY: POLICE DEPT. 0 , REPORT c /3 .2 WHERE REPORTED III!////NUMBER mod/ IF SO, WHO? f HEREBY DECLARE THAT THE FACTS STATED ABOVE ON THE FRONT ❑ SIGNED X iNA FRONT AND BACK ❑ ARE TRUE. - DATE S ��_ � (Year) eB'~' (sseu!$n~ ~o e~uoH) (e~3S '~C) '~eeJ3S pu~ ~equJnN) M ~ ~VN · xo~dd¥ aaaV~nN ~NOHd SS~'dQC]¥ ,, S~SS:~NJ.IM I:J:lH/O -IO aNY J:l¥O blnOA NI SI~!DN~SS¥cl 40 S:IS$~I:I(3QV aNY S:q~IYN 61N~FIAVd :10 NOIZlaNOO ~ [] &Q3.I.H~91'I 'I-I::IM JJN=laloo¥ 40 ::lOV3d SVM '.L-I :H/DN~-I 'S=lX al [] [] 6aVO aaH.LO :qNON [] ~MVO B~HIO [] [] &~VO M~H~O alo [] [] &N~OH ONROS noA ata [] ~ ~OaS'~r'~BONI [] [] ~a3onaau uvo U3H£O 6o3Banooc il ~43.L~¥ £N~OIOOV 3H~ -noev),,ava a3HZO ~C no~ AB 3OW 3M3~ S~3~3~VIS ~VH~ 6SNOI~I~NO0 ~gH~ ~M3~ ~VH~ 3NON ~ ~3AI9 noA ala 9VN~IS ~ ~ ~AOVd~I Ol aO~Ba BVO B3H~O aaS noA ~Mvo ~H~O O~ NO[INk,IV ~NON [] Hdl~ HdV~ 033dS 63B3HJ. $¥M "IOBJ. NOO 'J=l OlddV~LL/VHM uno,k a3±oYa~v IVHM 6BVO ~HZO '.~ 6nox 3BDM NOIIO~S -M~/NI ~OB4 BV4 MOH DNIg~AVM~ SYM BVO B~H±O NOI/O~IO ONV 3~¥N 9NI33AV~£ 3~3M ~OA NOl£O~la aNV 3~VN ~B/S SNOIIO3tdla 3..LVOIaNI ~ ~ SNDIS MO-IS Iq:iBiS HDV3 t:I3H.LO noA MO dO±S MOHS 93BV9 :SV S~VO MOHS '~HHVY¢ Ol~l~ A4OH9 'NOI~FI"'IO0 ~,0 -~I~VI.L .L V ~HI/O -,-I0 NOI. LI90~ E. L VE. LSR'ITI Bate: 03/29/2002 03:il3 pM Estimate ID: 6022 Estimate Version: 0 Preliminary Profile ID: Mitchell IWgB[E FINNIH I:ORD, 3600 DODGE STREET DEBt Q[ E, IA 52003 (563) 556-1010 Fax: (563) 690-1086 lax ID: 42-I074463 Assessed By: JEFF LEI(K T NKNO'~¥N DAVE FOLEV 206 DILLON DID, IA 52003 Home Phane: (563) 557-i912 i997 Ford Taurus GL iSDIe: 4DSed ViN: 1F~LP52U7VA ! 76024 Mitchell Service: 911623 Drive Train: 3.0L lnj 6 Cyl AO RE!- REFINISH BDY REMOVE/INSTALL BDY REMOVE/REPLACE BDY REMOVE/INSTAL!. BDY REPAIR REF REFINISH REF ADD'L OPR - .iudgell~ent Item : - Labor Note Applies C - included in Clear Coal Cale Line Item Description ~ L QEARTi,~R OUTER PANEL L Q1 kR~ ER PANEL OUTSIDE QUARTER ANTENNA ASSEMBLY L REAR MARKER LAMP ASSEMBLY REAR BUMPER COVER REAR BII~/IPER COVER REAR BEMPER COVER (:LEAR COAT PAINT/3dATERI<LS H ~ZARDOUS WASTE DISPOSAL Part Type/ Part Number Existing Existing E6DZ 15A20I D Existing ; ,Units Rate Labor Sublei 0.00 0.01~ {~ 346.50 T :5~ 6.000 % I }. 31.05 3~8 45.00 77 45.00 ~axab e Labor [ I : LaborTax ECALL NUMBER: 03/29/2002 i 4:57:i9 6022 APR_02_ 4.7.007 IL Part Replacement Summar~ Taxable Parts Sales Tax Total Replacement Parts Amount T ItraMate is a Trademark of Mitchell International Copyright (C) 1~94 - 2000 Mitchell International All Rights ReServed Dollar ~Labor Amount ~U~its ~ L0*# 9.70 3.85 * 6.000% Page 9.70 0.58 Date: 03/29/2002 03:~3 PM Estimate ID: 6022 EstimaTe Yerslan: 0 Preliminary Profile ID: Mitchell kmount ix,'. Adjustments 219.45 Customer Responsibility 219.45 I. Iota! Labor: IL Total Rep!acemen* Parts: tll. Total Additional Costs: Gross Total: IV. Total Adjustments: Net Totah Th is is a oreliminarv estimate. Addition~i chan~e~s to the estimate may be required for the actual repair. 548.55 10.28 219.45 778.28 03/29/2002 14:57:19 6022 APR_02 A 4.7.007 I ltraMate is a Trademark of Mitchell International Coovrioht C) 1994 - 2000 Mitchell International Ail Rights Reserved Page 2i