Claim by Donna J. CooksleyCLAIM 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 Attorneys 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. I
1. Name of Claimant: 0 NINA ^l C c ks l'ey
5 +
2. Address: � ! 1 ( 5 ' + • S - i • P. O . Go( ao a,
3. Telephone Number: L5L 3) O (o - 3 a 44 2
4. Date of Incident: F-1 4 --1 0
5. Time of Incident: S = c3 (. A • M •
6. Location of Incident (Be specific): N 6 Y es+ A ri P M a
R. T v q 1_a n I'4 S
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 the employee's name.) A5
W�c q ¢ - 4 - in q ► Mt" ` h e r, q�} L- Q-v�i rv.y
R 4 r q 1�a � ( ` . • e a , r- cc k%"---k .0e e C, r e v
A lc, co ceMe 's $ e, R�q
8. What were weather conditions like? N O R t a 1 S u M M Q (t D A y
9. Give name and address of any witnesses: N 0 ne.4
10. Did police investigate? (If so, give names of officers.)
No
No
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.)
Y es rty rear" u f pe-r M D u r -
rb c. 4 - 1,,ad be re Oa. cc 01 .
13. What other damages do you claim, if any? N O
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.)
0
No
15. What amount do you claim from the City of Dubuque? 9 V
16. Why do you claim the City of Dubuque is responsible? A (Z -e 4 t v■ q u e.Tt d n
l
5 La c-vc Le_ e. -�■ ccQ h S�
- +An, ck 4,5 C o m f r c.S ce n t a
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 this A 3 day of 0 e+61).42 (J 20
(Signature) y
(Print Name)
CA)
IC i:114316 SIB
Tauke Motor
BILL OR DONNA COOKSLEY
517 1ST STREET SW
PO BOX 202
EPWORTH IA 52045—
PHONE: HOME 563 876 -3242
OWNER 63242 UNIT# 4N248093
DELIVERED: 5/07/04
VIN: 1B3EL46X64N248093
WARRANTY: 7/70 POWERTRAIN
TRIM COLOR:
WARRANTY: 3/36
WARRANTY EFF: 5/07/04
1000 9th Street SE, Dyersville, Iowa 52040 563 875 - 7129
(C) 1. CONCERN: THE RIGHT REAR UPPER STRUT MOUNT BROKE.
CORRECTION: REMOVE THE STRUT AND REPLACE THE MOUNT.
LABOR:
THE SELLING DEALER MAKES NO WARRANTY OF
ANY KIND WHATSOEVER AS TO THE MERCHANT—
ABILITY OF THE PRODUCTS LISTED HEREON OR
AS TO THEIR FITNESS FOR ANY PARTICULAR
PURPOSE. ANY WARRANTY WHICH MAY EXIST IS
AN AGREEMENT SOLELY BETWEEN THE MANU—
FACTURER AND THE PURCHASER.
ESTIMATE
YOU HAVE THE RIGHT TO A WRITTEN OR ORAL ESTIMATE IF THE EXPECTED COST OF REPAIRS OR SERVICE WILL BE MORE THAN FIFTY DOLLARS. YOUR BILL WILL NOT BE
HIGHER THAN THE ESTIMATE BY MORE THAN TEN PERCENT UNLESS YOU APPROVE A HIGHER AMOUNT BEFORE REPAIRS ARE FINISHED. INITIAL YOUR CHOICE:
Written estimate. Orel estimate. No estimate. Cell me if repairs and service will be more than $
"I authorize the repair work described (Including parts and materials) and agree to pay for it in CASH unless otherwise agreed on this order. If the work is charged, I agree to pay your regular
finance charge. J understand that under Iowa law you may keen the vehicle unlit payment Le made You are not responsible for delays caused by unavailability of parts or delays in parts
shipments or for bss or damage to the vehicle or any articles left in It in case of fire, theft or any cause beyond your control."
DATE SIGNED
EXT: Y
C Olt Ft YSI_
CUST# 63242
2004 DODGE
TOTAL LABOR
TOTAL PARTS
REPAIR ORDER SUBTOTAL
*SALES TAX
REPAIR ORDER TOTAL
CHARGED TO CREDIT CARD, THANK YOU.
X
ALL PARTS REMOVED WILL BE RETURNED UNLESS INSTRUCTED OTHERWISE
(CUSTOMER'S SIGNATURE)
❑ SAVE ❑ DISCARD
: rr\I\ ?)E( c
CUSTOMER COPY
RO# C126393
START 8/14/10
BILLED 8/14/10
PO#
WRITER MJG
APPROVAL
PG 1
10:09
11:10
/MJG
STRATUS SX CURR MI 67,612.0
TRANS: 4 SPD AUTO
ENGINE: 2.4 4 CYL
COLOR CODE: PEL
TRIM CODE: A8DV
COLOR: RED
UNIT: $100 DEDUCTIBLE EXP:
73.04 *
73.04
.00
73.04
5.11
78.15
78.15
I'M, — uturtri FIPWILJJ, IFS rriccrwrii, IL LII.)/AL L.I I ICJ
155 N. Crescent Ridge 319-294-0881 815-235-3117 309-736-7500
lit 0 Dubuque, Iowa 52003
I
CLINTON, I A LANCASTER, WI WATERLOO, IA
4 Phone 563-556-3911 ;,r,
1-800-747-3911 563-241-1071 608 319
4 At.' Fax 563-556-5756 IOWA CITY, IA
AJ ft li, '
www.iwimotorparts.com 319-688-2842
DATE
NUMBER
: /1 .1 '." i C
i'.
CUSTOMER P.O. NO.
CUSTOMER NO.'
REFERENCE
SHIP VIA
SHIP DATE
TERMS
STORE
CODES
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PAGE
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SOLD
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CASCADE, IA
563-852-7059
DYERSVILLE IA MACHESNEY PARK, IL
563-875-8053
815-282-2168
TERMS: All accounts are due and Clerical errors are sub'ect to correction. Char. eable taxes inadvertently omitted, remain the purchaser's liability.
4 payable by the 10th of the month Tools, fuel and electrical parts are NOT RETURNABLE. Other return privileges are limited and must be exercised promptly.
following purchase. 11/2% per WARRANTY DISCLAIMER: The factory warranty constitutes all of the warranties with respect to the sale of all items. The seller hereby expressly disclaims all warranties,
i; month, 18% per annum service either express or implied, including any implied warranty of merchantability or fitness for a particular purpose, and the seller neither assumes nor authorizes any other person
, -.1,..,w will be added to all to assume for it any liability in connection with the sale of all items.
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