Claim Holland, TheresaCLAIM 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: Theresa Holland
2. Address: 2092 Theisen St., Dubuque, IA 52001
`
3. Telephone Number: 563 582 0074 cell # 563 580 7166
4. Date of Incident: 8/28/04
5. Time of Incident: 9:45 P.M.
6. Location of Incident (Be specific):
Fremont Street (between St. Joseph & Hale - top of)
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.)
Heavy rain - many deep pot holes (8" - 12" deep). I drove very slow and had to go around each hole, but they were very close together.
My car hit -draged bottom. I couldn't turn around once I started
8. What were weather conditions like?
Heavy rain
9. Give name and address of any witnesses:
Son - Ryan
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, exhaust pipe & muffler.
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.)
I, I carry insurance through American Family (I have $250.00 deductible)
15. What amount do you claim from the City of Dubuque?
$155.05
16. Why do you claim the City of Dubuque is responsible?
Because there were no warning signs - flashing lights- detour signs or a road closed sign. I assumed it was
travelable or I wouldn't have even attempted it. (It was dark also).
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 1st day of September, 2004. .
This is a huge expense for me (single parent) but I need transportation for me and my two children. Any help will be very much appreciated.
Thank you.
/s/ Thersa Holland
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Ce. II¡ UI
. .' ~LAIM AGAINST THE CITY OF DUBUQUE;IOWA ~ ~
This written report constitutes your claim against the City of Dubuque, low;. . ~ ýJou 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: )/¡~ J. ¿LA'^" 110 / fa ,J (J
2. Address:¿O c¡ 2-- - Tf, (I Sc: rJ Sfre-cÞ D l-ub~ /, e
3. Telephone Number: 5 (oJ - 5 '(¿- u 07 Lf cJl þ- 563 -S,?TÒ
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4. Date of Incident: 'l /2- '6/0 cl
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5. Time of Incident:
6. Location Of Incident (Be specific):
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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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9. Give name and address of any witnesses: ~. - R'f ÍI ¥"\ ~1iTI
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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 dameges.
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? /f/ðYl.J<--.,
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? /.:)". 0 ~
16. Why do you claim the City of Dubuque is responsible? ~11 Á.O. ~ A, ¡.(/¿( ~
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If y/PcgiVe name and address.)
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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 / ~ day ofS ~f-&¡v1 kLv1 . , 200 é{ .
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(Rev. 1/00 & 7/01)
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Midas Auto Service
1720 John F. Kennedy Road
Dubuque, IA. 52002
563-557-7525
ALUM. RIMS MUST BE RETORQUED AFTER 50 MILES
Invoice #1005222
Date: 8/30/04
Page: 1
Center: 1
Customer: HOLLAND, THERESA
Address: 2092 THEISEN
City: DUBUQUE, IA 52002~
Phone 1 : ( 563 ) 582-0074
Phone 2 : (563 )
Vehicle: 1997 NISS SENTRA
License: 018 FFA
VIN : 1 N4AB41DXVC769849
Engine:
Mileage: 53055
Ext:
Ext:
Op
OH
Tech
Quan
Description
Part Number
Part Descdption
Reason for Replacement
Service Requests,
front end check.. .check everything over.. .wait
D.O.:
Trans:
Wait:
Labor
Parts Subtotal
Price
WORLD IMPORT MUFFLER
Decline 0.00
A REQD~NO LONGER PERFORMS FUNCTION Declined
84.95
EX 00 105 INSTALL MUFFLER
0 1. 00 AZ7536
EX 00 10 INSTALL EXHAUST PIPE
681.00 UNIFLEX
UNIVERSAL FLEX PIPE
A REQD~NO LONGER PERFORMS FUNCTION
43.00
41. 95
41. 95
Experience The Midas Touch
Install protective coverings on steering wheel, seats and floor mats
Inspect lighting system, inspect tires and adjust tire pressure
Check oil level and Perform Midas Courtesy Check Inspection
WARRANTY INFORMATION
Midas International Corporation issues written warranties on mufflers, catalytic converters, shock absorbers,
strut assemblies, strut cartridges, brake shoes and pads, and variable rate springs. The warranty terms for
these products are stated on separate printed warranty certificates issued to you, together with the invoice,
upon the purchase of the appropriate warranted product. The terms of all warranties are in the Midas
Warranty Binder on display in each Midas location.
All other products and workmanship are warranted for ninety (90) days from the date of installation. There
are no other warranties issued by Midas International Corporation.
This warranry gives you specific legal rights; you may also have other rights which vary from state to stale,
Warranty work will be performed at any Midas location in the USA or Canada offering the warranted product
of service. For the address of your nearest Midas location, see the Yellow pages of the local telephone
directory or write Midas Consumer Relations, 1300 Arlington Heights Road, Itasca, IL. 60143. I hereby
authorize you andlor your agents to contact me regarding the products and services provided at Midas.
Thaok You For Your Patronage!
Labor: $43.00
Parts: $41.95
Sublet: $0.00
Other Fees: $0.00
Shop Supply $0.00
Subtotal: $84,95
Sales Tax: $5,95
Paid By: Total: $90,90
Check
Pay Ref: Paid: $90.90
Due: $0,00
Midas Auto Service
1720 John F. Kennedy Road
Dubuque, IA. 52002
563-557 -7525
ALUM. RIMS MUST BE RETORQUED AFTER 50 MILES
Invoice #1 005223
Date: 8/30/04
Page: 1
Center: 1
Customer: HOLLAND, THERESA
Address: 2092 THEISEN
City: DUBUQUE, IA 52002~
Phone 1 : ( 563 ) 582-0074
Phone 2: (563 )
Vehicle: 1997 NISS SENTRA
License: 018 FFA
VIN : 1 N4AB41DXVC769849
Engine:
Mileage: 53055
Ext:
Ext:
op
OH
Tech
Ouan
Part Dese,lp!lon
Reason to, Replaeemen!
Dese'lp!lon
Part Numbe'
ServIce Requests,
muffler
EX 00 105 INSTALL MUFFLER
0 1. 00 AZ7536
D.O.:
Trans:
Wait:
Labo,
Parts Subtotal
P,lee
WORLD IMPORT MUFFLER
A REQD~NO LONGER PERFORMS FUNCTION
15.00
44.95
44,95
59.95
NIS
War# MMO052028388
Experience The Midas Touch
Install protective coverings on steering wheel, seats and floor mats
Inspect lighting system, inspect tires and adjust tire pressure
Check oil level and Perform Midas Courtesy Check Inspection
WARRANTY INFORMATION
Midas Intemationa] Corporation issues written warranties on mufflers, catalytic converters, shock absorbers,
strut assemblies, strut cartridges, brake shoes and pads, and variable rate springs. The warranty terms for
these products are stated on separate printed warranty certificates issued to you, together with the invoice,
upon the purchase of the appropriate warranted product The terms of all warranties are in the Midas
Warranty Binder on display in each Midas location.
All other products and workmanship are warranted for ninety (90) days from the date ofinsta]latlon, There
are no other warranties issued by Midas International Corporation,
This warranly gives you specific legal righls; you may also have other righls which vary from state to state,
Warranty work will be performed at any Midas location In the USA or Canada offering the warranted product
of service, For the address of your nearest Midas location, see the Yellow pages of the local telephone
directory or write Midas Consumer Relations, 1300 Arlington Heights Road, !tasca, IL. 60]43. I hereby
authorize you and/or your agents to contact me regarding the products and services provided at Midas.
Thank You For Your Patronage!
labor: $15.00
Parts: $44.95
Sublet: $0,00
Other Fees: $0,00
Shop Supply $0,00
Subtotal: $59.95
Sales Tax: $4.20
Paid By: Total: $64,15
Check
Pay Ref: Paid: $64.15
Due: $0.00