Claim by Austin Karl MilliusCLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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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. 13 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 PAID.
1. Name of Claimant: A (.23 F/ K'tL M (L L 10 -S
2. Address: ---
(o "7 7 O , 1f 6-61 A D U/ It,( E
3. Telephone Number: �' j'Y eP 2 y 2
4. Date of Incident: D ' 2 S^ 2 d i c
5. Time of Incident: 00 j7 irv\
6. Location of Incident (Be specific): kit / L� -S J R E e T
o -t- E C'C 1C- e lf /C&9 1 & ) .S 74-7/6)/v ( ? /77 7/w/ 7) - /C)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
/V c�
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.)
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7'27 he(_ f / �-0-1 6( l f / 6/Yl /1-rat Sfr CO — tc4? dei-FJ,7 f ck:4ii-7
8. What were weather conditions like? k G //l / ic'
9. Give name and address of any witnesses: " ti Mi ///17 -' 761' 7rz(Ck /9, )/N
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10. Did police investigate? (If so, give names of officers.) = 9l-Le file /,
12. Was
damages.
damage.)
Y
any damage done to property? (If so, describe property and the extent of
Attach estimates of damages or describe basis for ascertaining extent of
97� lIv tqn %. 7/4 %i f2� l0(iJ -r4/ if , e // r ‘t4/-
13. What other damages do you claim, if any? Nt'
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? 73) S.
16. Why c(o you claim the City of Dubuque is responsible? T / •
at/ T�7 -C �� 1M P1 ' j c / j pre' b01 d /' rpi c 1 k7 7/ii
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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.) A/ 0
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 I3Jh day of I ��
Avon A') ii,v5
(Rev. 1/00 & 7/01)
, 20 %
(Signature)
(Print Name)
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STOCK, BRYAN
26777 N GRANDVIEW
DUBUQUE, IA 52001
563.663.1450
Store # 649120
Description
FIRESTONE TIRE WITH UNI -T, PACKAGE
184397 DESTINATION A/T OWL 31/10.5R15 C109R NO
MILEAGE WARRANTY
DOT# VN60DA21010
WARRANTY FOR DESTINATION AIT 31X10.50R15LT C 109R OWL
ORIGINAL ARTICLE #184397 PRICE 121.99 COLLECTED 31%
REMAINING TREAD DEPTH 11/32 SERIAL # VN60DA23209
TIRE -DISC DISCOUNT
7097782 ROAD HAZARD PROTECTION
TIRE DISPOSAL FEE (1)
TIRE INSTALLATION
ALIGNMENT CHECK - LIFETIME 1
Symptom: -
LIFETIME ALIGNMENT RECHECK
TIRE ROTATION - WARRANTY N/C
TIRE ROTATION
BRAKE SERVICE
WILL BE IN THURSDAY
7030260 WHEEL
ORDER NOTES
PUT ON CARD
INSPECTION
FROM PRIOR INSPECTION
Technician(s):
02 MARK SARAZIN
Payment History:
CFNA 3862
Total Tendered
Page 1 of 2
155.83 09051
155.83
RETAIL SALE
I have received the above goods and /or services. If this is a credit
card purchase, I agree to pay and comply with my cardholder
agreement with the issuer.
Customer Signature
Initial here to indicate you have received
the Tire Maintenance Warranty Book.
All parts are new unless otherwise specified.
www.ExpertTire.com
EXPERT TIRE STD LP 08 -18; 0881 REV 01;08 X08552
1998 DODGE DAKOTA
V8 -318 5.2L
Lic #: Vin #:
In: 05/25/10 2:27PM Mileage: 127,005
Out: 05/28/10 4:30PM
Rev Hist
/Article # ID
2 01
184397 02TN
7014012
7097782
7075078
7015016
02TN
02TN
02NN
02TS
01
7030260 02TN
cD G
Unit Extended
Qty Price Price
1 37.82 37.82
-1
1
1
7022837 02TS 1
1 01
7001121 02TS 4
2 09
1
37.82
18.30
2.50
N/C
N/C N/C
N/C N/C
125.00 125.00
Summary:
Parts
Labor
Shop Supplies
Sub -Total
Tax (7.00 %)
Total
Rev
Revision History: Amt
1) 05/25/2010 02:52PM 0.00 STOCK, BRYAN IN PERSON
2) 05/25/2010 04:08PM -14.54 STOCK, BRYAN 563.663.1450
-37.82
18.30
2.50
N/C
Job
Total
20.80
125.00
143.30
2.50
0.00
145.80
10.03
$155.83
Init
Inv1 100504.306102