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Claim Keuter, KristinaCLAIM 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: Kristina Keuter 2. Address: 2855 Timberline ` 3. Telephone Number: House 557 1520 work 582 1841 4. Date of Incident: 9 25 03 5. Time of Incident: Between 7:45 A.M. - 5:15 P.M. 6. Location of Incident (Be specific): 9th and Iowa Parking Lot #1 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.) The painting of the parking meter with car parked next to it, end result was paint on front end of car, meter wasn't painted at 7:45 but was at 5:15 along with the car. 8. What were weather conditions like? Partly cloudy 9. Give name and address of any witnesses: None 10. Did police investigate? (If so, give names of officers.) No 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, paint on front end of car 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.) No 15. What amount do you claim from the City of Dubuque? The amount money of the lowest estimate of repair 16. Why do you claim the City of Dubuque is responsible? Because the City of Dubuuqe employee painted the parking meter. 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? No Dated at Dubuque, Iowa this 1st day of October, 2003. /s/ Kristina Keuter (Signature) (Print Name) (Rev. 1/00 & 7/01) CLAIM 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: 2. Address: 3. Telephone Number:J{,¢ S'5 7 -/~-=~0 4. Date of Incident: ~*~'- 03 5. Time of Incident: 6. Location of Incident (Be specific): 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? ?~r?'~ ~]~.j)/ 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 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 amount paid.) 15. What amount do you claim from the City of Dubuque? 16. Why do you claim the City of Dubuque is responsible? J (If yes, give name and address.)~ d.~ 18. and if so, in what amount? Dated at Dubuque, Iowa this If the answer to Question 17 is yes, have you received any payment from that source, (Print Name) (Rev. 1/00 & 7/01) WILLIS AUTO BODY 1982 ROCKDALE RD DUBUQUE, IA 52003 PHONE: 563-583-9329 CD LOG NO 243-1 DATE 09/30/03 SHOP: ADDRESS: CITY STATE: ZIP: WILLIS AIKfO BODY 1982 ROCKDALE RD. DUBUQUE, IA 52003- INSP DATE: CONTACT: PHONE 1: FAX: 09/29/03 MARK WILLIS (563)583-9329 (563)583-9329 OWNER: ADDRESS: CITY STATE: ZIP: KEUTER, KEVIN 2855 TIMBER LINE DE. DUBUQUE, IA 52001- HOME PHONE: (563)557-1520 POINT OF IMPACT: 3 TYPE OF LOSS: /DRV LIC%: BODY COLOR: CONDITION: DARK GREEN STATE: VIN: MILEAGE: ACCTNG CTL%: 1G1JC5248T7223397 DRIVEABLE: YES VEH. INSP%: *=USER-ENTERED VALUE EC=REPLACE ECONOMY EU=REPLACE SALVAGE PM=PXN REMAN/REBUILT IT=PARTIAL REPAIR BR=BLEND REFINISH SB=SUBLET P=CHECK UP=UNRELATED PRIOR E=REPLACE OEM UC=RECONDITIONED PRT Ep=REPLACE PXN TE=PARTL REPL PRICE I=REPAIR TT=TWO-TONE N=ADDITIONAL LABOR AA=APPEAR ALLOWANCE NG=REPLACE NAGS UM=REMAN/REBUILT PRT PC=PXN RECONDITIONED ET=PARTL REPL LABOR L=REFINISH CG=CHIPGUARD RI=R&I /LSSFaMBLY RP=RELATED PRIOR 1996 CHEVROLET CAVALIER STD 4DOOR SEDAN CODE: U2344A/B OPTNS D/24V 4CYL GASOLINE 2.2 OPTIONS: TWO-STAGE - EXTERIOR SURFACES ANTI-LOCK BRAKE SYSTEM TWO-STAGE - INTERIOR SURFACES OP GDE MC DESCRIPTION EC Materials N clean,buff & wax frt MFG.PART NO. ECONOMY PART ADDNL LABOR OPERA PRICE AJ% B% HOURS R 20.00* 1' 2.5'1' 2 ITEMS FINAL CALCULATIONS & ENTRIES PAGE 1 19~6 CHEVROLET CAVALIER CD,,LOG NO 243-1 OTHER PARTS PARTS TOTAL TAxX ON PARTS @ STD 4DOOR SEDAN LABOR i-SHEET METAL 2-MECH/ELEC 3-FRAME 4-REFINISH 5-PAINT MATERIAL LABOR T OTA~L TAX ON LABOR SUBLET REPAIRS TOWING STORAGE RATE 45.00 50.00 50.00 45.00 26.00 REPLACE HRS GROSS TOTAL NET TOTAL ADP SHOPLINK U9956 ES CD LOG 243-1 DATE 09/30/03 HOST LOG (C) 1998 - 2003 ADP CLAIMS SOLUTIONS GROUP, INC. 7.000% REPAIR HRS 2.5 20.00 20.00 1.40 t12.50 112.50 7.000% 7.88 141.78 141.78 09:16:39AM R6.3 CD 09/03 PAGE 2 HART AUTO BODY & PAINT 800 CEDAR CROSS ROAD DUBUQUE, IOWA 52003 PHONE: (563) 556-8323 FAX: (563) 556-8324 DAMAGE REPORT PRICES SUBJECT TO CHANGE Items CIRCLED are not in the total in our opinion, are not part of this c~m. C LDR Or Pai.t Or Ho..i P~r~ Syn. LEFT RIGHT H~d Hinge R~R MISC. SERVICES ~, 6HRS, ~ Windshield Gas Tank SUBLET OR PAINTING Frame SUB TOTAL w.~ T~ Hub & Drum PAINT-MATRL-HDW.