Claim Sanchez, ChessicaCLAIM 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: Chessica Sanchez
2. Address: 3000 Carter Rd.
3. Telephone Number: 584 9882
4. Date of Incident: April 11, 03
5. Time of Incident: 9:15 P.M.
6. Location of Incident (Be specific):
Carter Rd. In front of home being built...After intersection Kane/Carter Rd.
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.)
It was dark at 9:15 P.M. I drive this road daily. Raised area was not visible when I hit the area. No signed. Equipment parked on the same side of road.
8. What were weather conditions like?
Clear
9. Give name and address of any witnesses:
Card enclosed Steve Ulstad 582 7334. Hit the raised pavement after me. Tore it out.
10. Did police investigate? (If so, give names of officers.)
Yes, J. Messerich 589 4424 03 13978
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.)
Yes
Anderson Weber - Estimate $720.00
Miller Auto Body - Estimate and repaired the car $301.39 (?0
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? $381.39
16. Why do you claim the City of Dubuque is responsible?
Picture enclosed. Unrepaired hole with raised pavement in City street. Police called to put up signs.
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 21 day of April , 2003.
/s/ Chessica Sanchez
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
· .
Th,s written report constitutes Your claim against the City of DubUqUe, ic~a. 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: ~..T~'~. , ~'~.~'~-6/~- ~
2. Address:
3. TelePhone Number:
4. Date of Incident:
5. Time of Incident:
P:/5,,~
6. Location of Incident (Be specific):
?. DE~C~E ACCIDENT O~ OOCU~NC~ THAT CAUSED INSU~Y O~ 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 lika?
~. ~i~ n~m~ ~d ~aa~ of ~ny ~it~s~s=
10. Did,police investigate? (If so, give n~mqs 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 amoant 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
(Rev. 1/00 & 7/01)
,20
(Signature)
(Print Name)
ANDERSON -WEBER, INC.
3450 CENTER GROVE DRIVE
Re. Box 933 TOYOTA
DUBUQUE, iOWA 52004-0933
(800) 776-3281
(563) 556-3281
www.andersonweber, com
F~e Service L~aners (a~p~intment rec~mmended) ° Free ~i~ (with new car purchase) ° Free B~dy Estirnates (ABRA `~)~ER
CINDY L. SANCHEZ
3(']00 CARTER
CUS'T'~f 1414
DUBU[.)UE ):A 5200 :l
I::'H6~NE: 56S
RO~ C6773~ PG
DATE 4/14/03 .... 4/14/03
WRI TEi;.! WN
APPROVAL WN IV;AS
I:.ROMZ SED 00/00/00
OW~,tE:R :i. 4:i. 4 L.q,.i:["i'~- Y¼6.[i'}Q;92'72000 Mti~:RCUI:itY MYSTT. QUIE
PROD DJ": 9/¢ 6/99
9EL :i:VERED: 10/09/99
VIFI: 11dlEFtq66L6YK60092'?
2ND KEY: 9LCABVFA
CYL]:NDERS: 6 CYL
GVWR:
EXT:
WAF;.tRANTY lEFT:'
CLIRR MI 5t., 09'7.0
CURR MT
'I'RANSM]: S.,~i; I ON: CI)4E
UN Z 7': EXP:
(C) 1, C(]NCEI;.$-!: C. USTOMMER HZT H]:GH SPOT :[i,.t F~OAD,STli']EF(]],I8 WHEEL
NO]:SE ]:N REEAR OF' YE:FI Ot~ SMOOTH SURF¢ICE.
ROCK WENT UNDER VEt'] ?
CORF~ECTION: ROAD T[:':ST.~DZRGIqOSE LEFT REEAR SPINDLE ]:S CRACKED~LEFT
~~T~ ..,..It::.L,K :[1:r ANYTI-i]:N8
W]:LL ~4f~b~J ~r[M...L SPZNDLE ¢:IFiI) AL];N,~TO f" ....
EL, SE IS BLENT.
SUBTOT¢~L LABOR
TO Ti::~l.,. LABOR
]"O'f'AL PARTS
REPA]:R ORi)ER SUBTO'-fAL.
~SAL. E:S 'TAX
"TOTAL AMOUNT DUE"
:i:9.5e~
19.50
19.50
19.50
1,, 17
~:]0 .. 6'7
The selling dealer makes no warranty of any kind whatsoever as ts'the merchantability of the products listed hereon or as to their fitness for any particular purpose, any warranty which may
exist is an agreement solely between the manufacturer and the purchaser.
"1 hereby authorize the repair work herein set forth to be done (including psrts and materials) and agree to make payment therefore in CASH, unless it is otherwise agreed and so set forth in
this order. If the work is charged, I agree to pay a finance charge of 18% annually if not poid in 30 days. I understand tha~ as a matter of Iowa law you may retain posession of the vehicle
until such cash payment is made. You are not responsible for any delays caused by unavailability of parts or delays in parts shipments nor for loss or damage to vehicle or articles lef[ in
vehicle in case of fire, thef[ or any other cause beyond your control." Permission is granted to operate this vehicle on any street or road far the purpose of testing and inspection.
Date Signed 20
X
PLEASE PAY FROM INVOICE, STATEMENT SENT BY REQUES]:
On behalf of servicing dealer, I hereby ca,fy that the information confa[ned hereon is accurate. Unless ethane(se shown, services described were performed at no charge to owner. There was
no indication from the appearance of the vehicle or otherwise that any part repaired or replaced under this claim had been connected in any way with any accident, negligence or misuse.
Records supporting this claim are available for (1 } year from the date of payment notification at the servicing dealer for inspection by representatives of Ford.
(~r~ed~ Dealer, General Manager or Authorized Person (Date)
CUSTOMER COPY
( uality z '
Auto Service
Multi-Point Inspection Report Card As Recommended by Ford Motor Company
Customer Name:
RO/Tag: Mileage:
OK ADD
· Transmission fluid level
Wont drive axle, dutch reservoir fluid (tr~ck onty)
4
4
· J~ [] , E~haust system (leaks, damage, bose paris)
l[~l lubdcateDrive shan, ,ransm,ssion, u jolut and shift/i*kage (if equipped) and(as needed)
l[~l Steean9 a~d steedng linkages and lubricate
[] ~ · Suspension (shocks/struts for bounce/leaks/damage) and lubdcate
Brake system (including lines, hoses, a~d pari~ng brake) and wheel
end for end play and beadng noise
Engine Cooling system, hoses and damps
Accessory ddve belt(s)
Battery terminals (dean ii necessary)
intervaJs pre-1999 vehicles)
Year/Model: Date:
MAY REQUIRE FUTURE ATTENTION J
Factory Spec Oold
CrankJn9 Amps
3 to 5mm or 4/32" to 7/32" {Disc) or 1.01 to 2rnm (Drum) or 2/32" to 3/32"
LF
7/32 or Greater
] 4/32 to 6/32
3/32 or less
TREAD DEPTH
RF
7/32 or Greater ·
4/32 to 6/32 ~
3/32 orless ·
7/32 or Greater ·
4/32 to 6/32 ~
3~2 or less ·
RR
7/32 or Greater
] 4/32 to 6/32
3/32 or less
LR
Service Advisor:
Technician:
Customer Signature:
2110802 Rev. 8/02 Customer Copy 004-- 1356696
7?0 CEDAR CROSS ROAD
Dubuque, L4
4/2 !/2003
Invoice
]168
.4Z,L PRO CONSTRUCTION
3000 CARTER RD
DUBUQUE IOWA 52001
Pea'ts &
5'~CH~ LAB...
AUTO ALIGN
Parts & Misc.
BALANCING
MOUNTING
i.$ LABOR
~UM mM
t Ti~ B~NC~G
I
Sales Tax
60,OO
44,00
.39,95
4.95
6,00%
60.00T
7920T
39,95T
!68,75T
6.95T
4,95T
2t
Total
$381.39