Claim Campbell, Marilyn ACLAIM 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: Marilyn A. Campbell
2. Address: 407 S. Broadway Maple Park, 12 60151
`
3. Telephone Number: 815 827 3556
4. Date of Incident: 2 9 04
5. Time of Incident: 1658 Hrs.
6. Location of Incident (Be specific): 1600 Clarke Drive
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 Bus Drivers Name is John Charles Tippe. Police Report is sent with. The City Bus hit the Driver Side
Mirror, breaking the glass.
8. What were weather conditions like? See Police Report
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Officer Narden Badge #59A
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.)
The Driver Side mirror was broke and had to be replaced.
13. What other damages do you claim, if any?
None
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?
$59.00
16. Why do you claim the City of Dubuque is responsible?
The City of Dubuque Keyline Transit bus hit the car and damaged the driverside mirror.
17. Have you made any claim against anyone else for damages as a result of this incident?
No
(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 25th day of March , 2004.
/s/ Marilyn D. Campbell
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
(If! ¡1~tf~~/
CLAIM AGAINST THE CITY OF DUBUQUEtlOWA ~
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: ~qÞ¡1 M .() ~yH¡J Je ~J
2. Address: f"ct? 5.. /fJr-",cwIø4.>j $¥hÆrAl; )J.
3. Telephone Number: g / .> - 8";2. 7 -3 S .5 6'
6015/
4. Date of Incident:
;:1..-179'-0 l;I
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5. Time of Incident:
6. Location of Incident (Be specific):
/CC7d vA-rite /Jr>/ve
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.) /7 .
:TA<:: ß<Js ,Øl,)..jþCYS; $q,;'11¿ /5 J",.,{h c;;íClY'/t:5 rìtf!/e" re1/;c.c tIf&/""...i::
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8. What were weather conditions like? See-. Ph lice If e.-£Jelr7
.
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
"" """;:;/ C &: /{ AI 4"'"'f 4'J . lI/ Æer..l:c;-;:i:I= $' 9/1
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
~o
12. Wàs'a'ny damage done to property? (If so, describe property and the extent of damages.
AttaclfesUmates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any? /t;"" n ð
14. Have you been compensated for any part or all of your claim by any insurance
company? (If so, give name and addressoLinsurance cqmpa_ny anc:l_.8rnollnt paid.)
4/d'
15. What amount do you claim from the City of Dubuque? /s 9. & d
16. Why do you claim the City of Dubuque is responsible? 7/;c ¿:,-t",;...f ¡j<l,rfu,cJc
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,17. Have you made allY claim against anyone else for damages as a result of this incident?
(If yes, give name and address..)
4/0'
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 ;2.5 tJ.- day of
"1\.. UÁ!Jv
, 20J#-.
'~[)~~
(Signature)
/VtßJ~ I ~i'\ \-¡tí"f!b~8ftp be. ¡I
8~~fih¡'; Namef:(O
(Rev. 1/00 & 7/01)
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MARIL.YN 0 CAMPBEL.L
4C7 S BReAWAY
MAPLE PARK IL 60151
Busin.ss Phone: (815) 827-3556
Home Phone: (815) 827-3556
300 SOuth Meln 8t...t
P.O Box 8028
Elburn, IL 80118
(I:SO) :S86.1481
SERVICE
INVOICE
oINE 1.
'ECH COMM:
INSTALL MIRROR GLASS
INSTALL MIRROR GLASS
~EPAIR 1. INSTALL
)PCODE: INSTALL
IRS: .20
'RIMARY TECH: 003
SALE TYPE: CASH - GM
$1.4 .00
PRICE SALE TYPE
4L550 CASH - GM
'ARTS
;M
DESC PP QTY
1236521.5 MIR-OS/RV N 1.
$41. 55
$55.55
--------------------------------------------------------------------------------
LINE TOTAL
CUSTOMER SIGNATURE
LABOR. . . . . . . . . . . . . . .
PARTS .........,.....
MISe MATERIALS .. ..,.
HAW MATERIALS,.. .. .
TAX (ILLINOIS STATE)
CUSTOMER TOTAL. . , . . .
PAYMENT (CASH/CHECK)
$1.4.00
$41.55
$.35
$,35
$2.75
$59.00
$59.00
, r',\~~~~:;\:
The Sfier, BOB JASS CHEVROlET. INC.. Herein Expre.1Iy
Diodalm' All w...,.nti8s. eltl18r Expre.. Or 1rnp1l8d. InGludln; My
llm¡>üed W....nty Of Me,oh",,"bliity Or Fi..... For A portioulor
Purpose, And, !':oithor Assum" Nor AUthor, i,e. Any Other Porson
To Assume For 1\ Any Liobility In Connoctlcn Wlih The S8I8.
NOT RESPONSIBLE FOR LO" OR DAMAGE TO CARS Oft ARTICLES LEFT IN
CARS IN CASE OF FIRE. TllEFT OR ANY OTKER CAUSE BEYOND OUR coNTROL
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