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Claim Dieter, PaulaCLAIM 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: Paula Dieter 2. Address: 2436 LaVista Ct. 3. Telephone Number: 563 556 0529 4. Date of Incident: 6 14 02 5. Time of Incident: A.M. 6. Location of Incident (Be specific): Kaufman 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.) Street was not marked Wet Paint and the drivers side of my car is covered in yellow paint. 8. What were weather conditions like? Good 9. Give name and address of any witnesses: 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.) Car estimate 13. What other damages do you claim, if any? None 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? $249.10 16. Why do you claim the City of Dubuque is responsible? Street not marked 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 17th day of July, 2002. /s/ Paula A. Dieter (Signature) (Print Name) (Rev. 1/00 & 7/01) - - -cL^ M ^G^ .ST T.E C,TV OF DUBUOUE OW This written report constitutes your claim against the City of Dubuque, IoWa. Yo'u~s~b~dld complete this form in full and aEach any additional information that suppose 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 referr~ by the City Council to the appropriate department for investigation. Once that investigation is completed, a repo~ and recommendation will be submiffed 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 CI~ OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. Claimant: 1. Nameof ~ _______ 2. Address: ~ 3. Telephone Number: 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 8. What were weather conditions like? ~-~ 9. Give name and address of any witnesses: 10. Did police investigate? (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, ifany? ~ o ~.~ 14. Have you been compensated for any part or all of your claim by any insurance corn pany? (If so, give name and address of insurance company and amount paid.) 15. What amount do you claim from the City of Dubuque? you claim the City of Dubuque is responsible? .~_~;~ ~-~ ~ 1 6. Why do 17. Have you made any claim against anyone else for damages as a result of this incident? (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, iowathis /~ dayof ~ , 20~-~. LU © --- (Signature)~.~ ~ ~ ~ ~ (Print Name) (Rev. 1/00 & 7/01) WILSON BROS. DODGE 90 JFK DUBUQUE, IA 52002 PHONE: (319)583-5781 CD LOG NO 1916-1 DATE 07/17/02 SHOP: ADDRESS: CITY STATE: ZIP: WILSON BROS AUTO BODY 90 JFK FED TAX ID 420779647 DUBUQUE, IA 52002- INSP DATE: CONTACT: PHONE 2: FAX: 07/17/02 ROGER AUDERER (563)556-6928 OWNER: ADDRESS: CITY STATE: ZIP: DEITER, PAULA 2436 L VISTA DR DUBUQUE, IA 52002-2705 HOME PHONE: WORK PHONE: (563)556-0529 (563)557-4349 POINT OF IMPACT: 3 DAYS TO REPAIR: 0 LIC%: BODY COLOR: RED CONDITION: EXCL STATE: VIN: MILEAGE: ACCTNG CTL#: 2B3HD46R7XH813105 29,458 DRIVEABLE: NO PROD.DATE: VEH. INSP%: PAINT CODE: PH2 *=USER-ENTERED VALUE EC=REPLACE ECONOMY TE=PARTL REPL PRICE I=REPAIR TT=TWO-TONE N=ADDITIONAL LABOR AA=APPEAR ALLOWANCE E=REPLACE OEM EU=REPLACE SALVAGE ET=PARTL REPL LABOR L=REFINISH CG=CHIPGUARD RI=R&I ASSEMBLY RP=RELATED PRIOR NG=REPLACE NAGS EP=REPLACE PXN IT=PARTIAL REPAIR BR=BLEND REFINISH SB=SUBLET P=CHECK UP=UNRELATED PRIOR 1999 DODGE INTREPID STD 4DOOR SEDAN CODE: N2813A/B OPTNS A/45C 6CYL GASOLINE 2.7 OPTIONS: TWO-STAGE- INTERIOR SURFACES HEATED REMOTE CONTROL MIRRORS THREE STAGE - EXTERIOR USER DEFINED OP GDE MC DESCRIPTION I BUFF PAINT OFF CAR N UNDERCOAT WHEEL WELLS MFG.PART NO. REPAIR ADDNL LABOR OPERA PRICE AJ% B% HOURS R 4.0'1' 8.00* 0.3'1' 2 ITEMS FINAL CALCULATIONS & ENTRIES OTHER PARTS 8.00 PAGE 1 . ~999 DODGE INTREPID STD 4DOOR SEDAN CD LOG NO 1916-1 PA~TS TOTAL TAX ON PARTS @ 6.000% LABOR I-SHEET METAL 2-MECH/ELEC 3-FRAME 4-REFINISH 5-PAINT MATERIAL LABOR TOTAL TAX ON LABOR SUBLET REPAIRS TOWING TAX ON TOWING STORAGE RATE 40.00 48.00 45.00 40.00 25.00 REPLACE HRS REPAIR HRS 4.3 @ 6.000% @ 6.000% GROSS TOTAL NET TOTAL ADP SHOPLINK UB303 ES CD LOG 1916-1 DATE 07/17/02 04:16:44PM R6.25 PXN:N/00/00/00/00 CUM:/// HOST LOG (C) 1998 - 2002 ADP CLAIMS SOLUTIONS GROUP, INC. 8.00 0.48 172.00 172.00 10.32 55.00 3.30 249.10 249.10 CD 07/02 LIFETIME WARINTY ON PAINT ONE YEAR ON WORKMANSHIP NO WARINY ON RUSTWORK PAGE 2