Claim by Stephanie SchadlRECEIVED
10 JUL 15 AM 10: 26
City Clerk's Office
This written report constitutes your claim against the City of Dubuque, Iowa. You should comple@abOgn 3 fuOnd
attach any additional information that supports your claim.
The claim must be filed with the City Clerk at City Hall, 50 West 13 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.
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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 daim will or will not be paid.
1. Name of Claimant s phw tA�i f LUf�.�,
2. Address: . 1 . 70 Y 1 (O Lt CTt>
3. Telephone Number: 56
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4. Date of Incident: ka — /0
5. Time of Incident: 3. 30 ( 1' \
6. Location of Incident (Be specific): V + r I l - ! (•
- The t n I L part<l o --- C itVect. hlkt
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7. Describe the accident or occurrence that caused injury or damage (G
claim. If a City employee was involved, give the emplo n
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8. What were weather conditions like?
9. Give name and address of any witnesses: MIL \ D
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10. Did police investigate? (If so, give names of officers.) 4 . 4 sid
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11. Was anyone injured? If so, give names, addresses, an extent Windu
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12 Wa 4n9mage f one to • . if6, deers • - property an. R
damages or describe basis for ascertaining extent of damage.)
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13. What other damages do you claim, if any? Nilne,
16. Why do you claim the City of Dubuque is responsible
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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.)
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What amount do you claim from the City of Dub
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Have Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and
add C1 w!o Side,
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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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ESTIMATE
DATE
167893
07/13/2010
2:24p
ACCT
EMPL ID
31121
ERIC
PO
THE ,BIKE SHACK
3250,Dodge St.
Dubuque-IA 52003
www.thebikeshack.com
(563) 582 -4381
Bill To:Marty Schadl
3170 Keokuk Ct
Dubuque IA 52001
USA
H(563)580 -0067
no email
QTT DESCRIPTION
PRICE EA EXTENDED TOTAL
Entry Date: 07/13/2010 Est Comp: 07/14/2010
Sri* WTU2262036P Desc: MOUNTAIN BIKE
Mfg: TREK Model: 930
2 Brake Install ATB brake lever
Includes adjustment.
1 BR7419 Tektro Tenera Linear Pull Brk Levers
Black /Silver for Rapidfire, with Kraton
insert Black /Sil
1 Der hanger align and adjust
1 True rim REAR
1 Derailleur Adjustment front
Adjustment of front or rear der.
1 SA0010 MENS ASSORTED SEAT
*167893*
20.00 40.00
19.99 19.99
20.00
15.00
This can be as much as $ 25.00 depending on the severity of damage.
20.00
15.00
10.00 10.00
4 ..5 i .00 qi✓ 1 Ict
ESTIMATE
Acct: 31121 Ref: 167893
40.00
19.99
20.00
15.00
10.00
Pg 1 of 2
SUBTOTAL
Sales Tax
TOTAL
AMOUNT RECEIVED
BALANCE
DEPOSIT
8.10
+
0.00
12ti.38
ESTIMATE
DATE
167893
07/13/2010 2:24p
ACCT
YAWL ID
31121
ERIC
PO
THE , BIKE S}IACK
3250,Dodge St.
Dubuque.IA 52003
www.thebikeshack.com
(56'3) 582 -4381
Bill To:Marty Schadl
3170 Keokuk Ct
Dubuque IA 52001
USA
H(563)580 -0067
no email
QTY DESCRIPTION
PRICE EA EXTENDED TOTAL
Entry Date: 07/13/2010 Est Comp: 07/14/2010
Sri* WTU2262036P Desc: MOUNTAIN BIKE
Mfg: TREK Model: 930
$650.00 brand new.
Bike Repairs done right by expert mechanics!
*167893*
ESTIMATE
Pg 2 of 2
SUBTOTAL
Sales Tax
TOTAL
AMOUNT RECEIVED
BALANCE
DEPOSIT
119.98
8.40
128.38
0.00
f 7S
Acct: 31121 Ref: 16789