Claim by Lakesha Wheeler 5 1 09__ _
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CLAIM AGAINST THE CITE' 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 West 13t" 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 will not be paid.
1. Name of Claimant: G~ ~~ S, h~ ~~~0~ P/
2. Address: ~~~~ ~~~P ~~~f" f
3. Telephone Number~,~~~~ `~ ~s'
4. Date of Incident: a- '~
5. Time of Incident: ~ 1 ~
6. Location of Incident (Be specific):
8. W at were `~~eather conditions like?
9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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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
+ho cmnlnvca'c namca 1
11. Was anyone injured? (If so, ~ive names, addresses, 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.) _
13. What other damages do you claim, if any?
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15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is r ponsibl ?
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17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
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(Print Name)
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.)
~pehing A QUOTATION TO:
Specialists Lakesha Wheeler/COD
1202 White Street, Apt. 1
hC. Dubuque IA 52001
Attn: Lakesha Wheeler
Builder's Hardware,
Hollow Metal, Wood
Doors and Accessories
Business office: April 27, 2009
430 Main Stn3et Repair Rear Exterior Door Jamb
P.O. Box 430
Holy Cross, IA 52053 We are pleased to quote on the following material and labor per your request:
Phone: (563) 870-2018
Fax: (563) 870-4018 1 Piece, 1" X 5" X 42" lumber
1 Piece, 1-1/2" X 2" X 12" lumber
1 Full lip strike, 10-026 - 2-1/4"
Sales Office: 1 Service call
735 Century Drive 1 Cut/remove existing trim board
Dubuque, IA 52002 1 Cut/remove existing strike jamb
Phone: (563) 583-8082 1 Install new strike jamb section
Fax: (563) 583-8262 1 Install new trim board section
1 Install new strike
Customer Information
Phone
563-495-7414
Fax ALL THE ABOVE FOR THE SUM OF X216.60
7A0°o SALES TAX ~'!LL SE a.^.Ef1=C TD THE ;HOVE SJIA, IN THE AMOUyT DF S'15.16
ALL THE ABOVE FOR THE TOTAL SUM OF ;231.76
• The above prices will be void thirty days from the date of this quotation.
SIGNATURE OF • Material and/or labor price as listed above is net, fob job site location.
ACCEPTANCE • The buyer is responsible for all applicable taxes and will be billed accordingly.
• If material and/or labor purchased is to be exempted from sales taxes, a tax exempt certificate
or tax identification number must be presented along with the authorization to proceed.
• The above prices do not include handling and unloading at the job site unless labor to
install the material is included.
• We appreciate the opportunity to provide the above quotation to you. Please advise if
we may be of further assistance in this or any other matter. Thank you.
Sincerely,
1ZAIE ~~.
~~ ~ ~3- Sig o3~~
Tom Pape
Opening Specialists, Inc.