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Claim Mess, JamesCLAIM 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: James Mess 2. Address: 605 Garfield ` 3. Telephone Number: (563) 556 2632 4. Date of Incident: 9-11-03 5. Time of Incident: 8:30 A.M. 6. Location of Incident (Be specific): Garfield and Johnson 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.) My pickup was towed. Garfied is being repaired. I parked on Johnson St. 12 to 15 feet from corner. Called House at 8:15 A.M. Towed at 8:30 A.M. 8. What were weather conditions like? NA 9. Give name and address of any witnesses: NA 10. Did police investigate? (If so, give names of officers.) Police Order Tow 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). N/A 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.) N/A 13. What other damages do you claim, if any? N/A 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? $48.15 for Tow; $5.00 for ticket 16. Why do you claim the City of Dubuque is responsible? Police order tow when I was not parked illegal and the paving companyplaced No Parking Sign after I parked. 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) No 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 21st day of September , 2003. /s/ James Mess (Signature) (Print Name) (Rev. 1/00 & 7/01) AGAINST THE CITY OF DUBUQUE;"tOWA ..... This written report constitutes your claim against the Ul[y 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~h 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. 2. Address: 3. Telephone Number: 4. Date of Incident: 5. Time of Incident: 6. Location of lncident (Be specific): ~'/'~,,~/_,,~'~/__./'~ --~ ~O/-//~/(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.) 8. What were weather conditions like? 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names 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 ;e~.te~3{ 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 amount paid.) 15. What amount do you claim from the City of Dubuque? g-//. ~'-,Y'_5-~ /'~,'~/' ~-O/x~/ 16. Why do you claim the City of Dubuque is responsible? ~°O Z//~- ~,/"~.~ /"~/~/ 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 ~/----,/~/-- ., 20 ~...~.. ~ -- (Signature) - - (Print Name) (Rev. 1/00 & 7/01) ROad 24,Hour T~owing Service Service 275 Salina St;. 'Dubuque~ IA 52003 563-556-6480 Fax 563.556-3015 MasterCard & Visa Accepted S ICE IM EXTRA PERSON ~OTAL el( ....... . REASON FOR TOW SPECIAL EQUIPMENT ~ UNREGISTERED D BR~K DOWN ~ IMPOUNDED ~ SNATCH BLOCKS ~OW ZONE ~ LOCK OUT ~ ~ ~ SCOTCH BLOCKS D s~ow ~OVA~ D START '~ ~ '~ D OOLLY ~PE OF TOW TOWED PER ORDER OF VEHICLE TOWED TO WHEEL L[~ OWNER ~ILEAGE CHARGE ~ ' 1 8 7 i 9 N~ ~sponsib,e for loss or damage ,o vehicle Thank You