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Claim by Dave GrantCLAIM 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 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. 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: L t/ e & Y41+ ;z - / .sf, 3. Telephone Number( T S 22 ' �` 9T 0 11 /id / :00 pr? 2. Address: 4. Date of Incident: 5. Time of Incident: 6. L c on of In iden (Be specifi / /, e y' ,Je n apoo � / Eraahla +rz4- 'ii &'. 8. What werewather conditions like? 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 th- employee's name.) ©in up ke / / /Py late/ - r.� i,�. . • 9. Gve name and address of any witnesses: 10. Did olice investigate? (If so, give name of officers.) rc ,liza f rl iit'/ &r a / rit 11. Wa 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? ,I y e( 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. Wh mount do ou claim from the City of Dubuque? O6. s 16. Why do y u claim the Cit of Dubuque is responsible? .Slrvcs ic /1411e City eh,/ /3 e,1e harms e&C 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) 410 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated is '7 d of /96/9'(4 Sf 442 (Signature) (Print Name) , 201 (). VI `enbngna 03! 110 s \1 1O x(1!3 I£:110 9-911V (A CBAIIIAEJ URDE AUTO GROUP. COM CHEVROLET • BU ICK • SUZUKI FORD•CHRYSLER• DODGE•JEEP To David Grant 54 Diagonal St. Dubuque 52001 IA Case: 1 vehicle towed in roadside assistance Quantity Description /Correction vehicle towed in roadside assistance - Warranty IOW 780 Rt. 35 N East Dubuque, IL 61025 1- 800- 947 -8633 Fax 815- 747 -7721 Year: 2008 Veh Id: 70066 Unit Make: Chevrolet Model: Malibu 1 LT Color: WHITE V.I.N. #: 1 G 1 ZH57B 184266323 Date In: 08/02/2010 Out: 08/03/2010 Ext. War: - - ( mo /) - D: $0.00 Promised Time: 08/02/2010 03:00: #:84266323 License #: Odo. In: 5,864 Odo. Out: Next Service: In Service Date: 05/22/2008 Cases: 2 R /Lab. Rate 70.00 00 PM Call When Ready: No , Misc $0.00 Labor $0.00 Parts $0.00 Prepaid Parts Amt: $0.00 Case: 2 customer hit pot hole and right front tire is flat Quantity Description /Correction 1.00 1007078 - 225/50R17 1.00 9596921 - Cover customer hit pot hole and right front tire is flat * ** - Tech Cause: right front tire cut hubcap bent * ** - Tech Comments: ordeer tire, replaced tire and hub cap Completed by Technician number: 1001 Miscellaneous (Extra Item) Misc $2.23 Labor $31.90 Parts $216.53 Prepaid Parts Amt: INVOICE ORIGINAL Work Order #125916 August 02, 2010 Svc.Adv Fluhr, Casey Cust.Ph. (563) 582 -4990 Tag# Page 1 of 1 08/03/2010 17:32:46 Retail $136.54 $79.99 Price Total $0.00 $0.00 $0.00 $0.00 Case Total: $0.00 Price Total $136.54 $136.54 $79.99 $79.99 $31.90 $31.90 $2.23 $2.23 $0.00 Case Total: $250.66 $0.00 0 u T Indebtedness is hereby acknowledged for the 'Total Charges" being all or the balance owing to repairs, parts & accessories described in this work order 08/03/2010 Date Currency Payment Ref: Expiry Date: P /O #: Signature I Payment Type Cash Labor: Parts: Misc: Sub Total: Tax: $31.90 $216.53 $2.23 $250.66 $15.86 Total: $266.52