Claim Munson, Nicole
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. ' ~ CLAIM AGAINST THE CITY OF DUBUaUE,IOWA. ~~ ¡
. This written report constitutes your claim against the City of Dubuque, low;' XJo~ .s~~
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. 13111 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:
Nicole. Munson
2. Address:
736 University Avenue, Apt. #4
.3. Telephone Number: 495-6423
4. Date of Incident:
Aucrust 9, 2004
5. TIme of Incident:
8:00 a.m.
6. Location of IncIdent (Be specific):
736 University Avenue
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.) .
I was traveling west on University Avenue to my apartment when themuffler.on m~
car fell off due to the ruts and holes in the street from the construction being
done on University Avenue
:,.
8. What were weather conditions like?
Cloudy
9. Give name and address of any witnesses:
None
10. Di.d police investigate? (If so,give names of officers.)
Nn
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Nn
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.)
Burnes and ruts in the road from street construction broke the muffler off
my car (estimate attached)
13. What other damages do you claim, if any?
Nnnp
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?
16. Why do you claim the City of Dubuque is responsible?
'!'hp ri ty i" thp f'~rty
responsible for the construction being performed on University Avenue. There is no
other way I can access my residence without driving on the damaged road.
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
1 <th
day of
~,., . , 2O.QL
~~~~
- - - (Signature)
Nicol", Mím<:on
(Print Name)
(Rev. 1/00 & 7/01)
'Each Shop Individually Owned and Operated"
www.meinake.com
CENTER #645
2195 CENTRAL AVENUE
DUBUQUE. IA 52001
(563) 582.6489
"'~~UMi~
Invoice Number: 1576
Invoice Date: 08-17-04
Payment Method: Deferred
me' neke@
car care center
SOLD TO:
s MARK MUNSEN
0 ~ 3920 HILLCREST
~ Dubuque. IA 52001
0 Vehicle
1993 OLDSMOBILE CUTLASS CIERA
(563) 589-4341
Odometer I!!g
0 IA N
Vin
Tech
MB1
Writer Ad Lead
MBl REPEAT
Quanti
Item
Descri tion
Warran
ND MAP Unit Price
Total
EXHAUST
1.00 19910
1.00 MISCPART
1.00 EL7853
1.00 X200
1.00 1
PREM SHOP MUFFLER
LIFETIME MUFFLER
CONNECTING PIPE
CLAMPS HD
EXHAUST INSTALLATION
1 Year
A
D
A
A
A
45.95
0.00
54.62
1.99
15.50
45.95
0.00
54.62
1.99
15.50
1 Year
1 Year
0.00 MEMO
SMALL LEAK AT FRONT GASKET ASSEMBLY
A
We want to thank you for your patronage. At MEINEKE, your satisfaction is very important to us.
, MaD Code Leaend
Sl=Sugg-Failure Likely
S2=Sugg-Customer Rea.
S3=Sugg-Maintenance
S4=Sugg-Reccmmendation
RA=Req-Perfonnance
RB=Req-Design Spec
RC=Req-Missing
AID Leoend
A=Accepted
D=Declined
Customer Copy = White
Sales Tax: 8.54
Shop Copy = Yellow
0.00 0.00
0.00
Estimate ID: 002041
Validation Code: 12963Z12732J10266
~:~'~~~F W~N~ OF RECEJI'T.
S~Q# 109524
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