Claim Mattoon, DeanCLAIM 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: Dean Mattoon
2. Address: 1380 Reeder Street
3. Telephone Number: 583 6196
4. Date of Incident: 10/31/02
5. Time of Incident: 5:30
6. Location of Incident (Be specific): In front of 755 Chestnut St
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.)
Popped front tire of van on a 4"-5" piece of Rebar sticking out of the street.
8. What were weather conditions like?
clear and cold
9. Give name and address of any witnesses:
Jake Schubert, 755 Chestnut
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.)
Popped front tire of van
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?
65.72
16. Why do you claim the City of Dubuque is responsible?
Rebar from City Street caused the damage
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?
No
Dated at Dubuque, Iowa this 6th day of November , 2002.
/s/ Dean Mattoon
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE~qOWA '
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:
2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident: :~-.- 30
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
employee's name.)
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, 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.)
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
~,~ day of
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
WAL-MART'
ALWAYS LOW' PRICES, ALWAYS WAL-MAR'E
NE SELL FOR LESS
MRNAGER MARTIN PARKHURST
( 563 ) 582 - 1003
5T~ 2004 OP~ 00000270 TE# 32 TR8 02801
TLR ZTEHS FOLLOW
ORDER NUMBER 0048570075471
TZRE VIVA 2 069756203778 54,96 d
T~REPROTPLRN 068113112925 8.01 d
VALVE STEM 007874241271 1.75 J
DZSPOSRL FEE 007874253258 1.00 A
TLE ZTEM5 COMPLETE
SUBTOTAL 65,72
HRTON PL BAL 002460001001F 0,38 H
SPZCE 004135151755 F 0.75 H
BRKINO SODA 003320001130 F 0.33 H
CR SHORTENZG 0037000,40000 F 1.36 N
aNIMAL CKRS 004400000379 F 0,87 D
FRAME 003855536821 5.00 d
FRAME 003855596821 5.00 J
SU~TOTRL 79.41
TRX I 6.000 X 4,54
TOTRL 83,95
DEBZT TEND 83.95
CHANGE DUE 0.00
EFT DEBZT PAY FROH PRZHARY
ACCOUNT : 6109
83,95 TOTAL PURCHASE
REF 8 230900443961
NETWORK ZD. 0055 APPR CODE 087908
11/05/02 11:34:12
# ZTEHS SOLD 11
TC~ 9317 5551 8785 7453 7785
II lift II g ll U 11 11 Illlll II Illl
LAYAWRY ~
EXPRESS ON 5[FT REGISTRY KZOSK
11/05/02 11:34:17
DATE
11-05-2002
YEAR
1992
STORE# 2004
4200 DODGE STREET
DUBUQUE, IA 52003 US
(563)582-1003
LIC# IOWA
Service Order:
NAME
MATTOON, AMANDA
MAKE
CHEVROLET
1380 REATER ST
DUBUQUE, IA 52001
MODEL
LU3/IINA
PHONE #
(563)583-6196
COLOR
Black
ODOMETER CUSTOMER ARRIVAL TIME SERVICE COMPLETED TIME
******** 11111 2002-11-05 10:34 AM 2002-11-05 10:48 AM
LICENSE
Service Description Service
NEW TIRE
- Tire Pressure - CHECKED, Ft.32 R.0
TIRE PROTECTION PLAN
- Valve Stem - Install - COMPLETE
- N/C Tire Mount
DISPOSE T/RE
- Dispose Tire - COMPLETE
LUG TORQUE
Passenger Front 100 FT-LB
TI~AD DEPTH
Passenger Front - 0/32
New Tires - COMPI~TE DOT: PDMOFiTHR3202
Tire Wm'rauty Accepted
Balance (Required) - COMPLETE
0.00
8.01
1.00
Merchandise Description Merchandise
Quantity unit Price
1 54.96
1 1.75
Total (Excluding Tax)
P205/70R15WW VIVA 2
VALVE STEMS TR-413
Technician Comments
54.96
1.75
65.72
DISCLAIMER
11-05-2002
CUSTOMER SIGNATURE DATE
aVE YOUR LUG NUTS RETORQUED AFTER THE FIRST 50 MILES.
4 s7oo 75471
SIGNED
DATE