Claim Merges, Sarah J.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: Sarah J. Merges
2. Address: 1740 Northern Valley Dr. NE Rochester, MN 55906
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3. Telephone Number: 507 529 0164
4. Date of Incident: 7 20 04
5. Time of Incident: AM
6. Location of Incident (Be specific): 2593 Fulton St., Dubuque, IA 52001
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 van was parked in front of parents home on a dead end street. The only traffic is 2 neighbors next to my parents. When I went to leave I noticed van mirror flipped wrong direction and long pant scratch on mirror. Paint marks on mirror are white and black. During morning hours I did notice garbage and recycling trucks next to my
vehicles. They were parked close while getting garbage. No other traffic was noticed that morning.
8. What were weather conditions like? Sunny & Warm
9. Give name and address of any witnesses:
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, Drivers' side mirror of 2003 Honda Odyssey was flipped wrong direction and paint scratched off in 2 plates.
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? $269.58
16. Why do you claim the City of Dubuque is responsible?
The location and lack of traffic on this dead end street along with seeing garbage and recycling vehicles parked next to van is the only way van mirror could have been damaged.
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 28 day of July, 2004.
/s/ Sarah Merges
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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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.
"
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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.
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3. Telephone Number: Eh7 - L599-(v(oc!
4. Date of Incident: 7-c3ð-C/}
5. Time of Inciden./.þ-/)
6. Location of Incident (Be specific):a59?)
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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.)
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8. What were weather conditions like? ~ \.À)G..f n~t- 1D { UtJud.w - I
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9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone Injured? (If so, give names, addresses, and extent of injuries).
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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.)
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13. What other damages do you claim, if any? I.. Y'flO ,
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.)
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15. What amount do you claim from the City of Dubuque? -G.. ( 0 q - 58
16. Why do you claim the City of Dubuque is responSible?MO /èrcp'a) Ora
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17. Ha3k you made any claim against anyone else forfdàmages as a result of this incident?
(If yes, give ní\..me and address.)
Do
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
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Dated at Dubuque, Iowa this að'
(Rev. 1/00 & 7/01)
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ESTIMATE OF REPAIRS ~~~~~IEf:R~~~~~~ ~~~ ~1~1~~~L~STIMATES FREE
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~ TOM KADLEC
PONTIAC 0 HONDA
4444 HIGHWAY 52 NORTH / ROCHESTER, MINNESOTA 55901
507281,2500
OWNER
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ADDRESS / 7 ~ 0
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LICENSE NUMBER
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507.281.2500 ".,.'."."'..
Service 507.280.2200 ~.'.'..".,..,"'...'.'.F' .
Toll Free 877.381.2500 <~. .;.., 19
Fax 507.280.2239 . "N
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Steve Kroeger
Service Advisor
4444 Hwy 52 N . Rochester, MN 55981 . tornkadlec.corn
BY OWNER
OR AGENT
(692.04749) ,""'M'
DATE
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