Claim Holland, Theresa
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. .' ~LAIM AGAINST THE CITY OF DUBUaUE,.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: ))¡....v.. J. L1 AA, I-h / / a rJ (]
2. Address: 2.-0 c¡ 2-. Tf¡ [I SC?l Sfre.& [) ih/]ÜC/ e
3. Telephone Number: 5 (03 - 5 ? ¿ - u 0 7 <-( cJ1 pi. ¿j t9 3 -,SIT ò
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4. Date of Incident: "ð /2-. '6/0 lj
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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 't n 'v\. 1â:""Y
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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 daimlges.
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? ß/o'YLfL,..,
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? / S' ~ ,OS
16. Why do you claim the City of Dubuque is responsible? ~lÁÁ'O.~..i A 0-£/1-( J
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If y.iV;give 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 ¡.d-" daYOfS~f£1'Vl.l:u/¡. ,20dLf.
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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
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: 1N4AB41DXVC769849
Engine:
Mileage: 53055
Ext:
Ext:
op
OH
Tech
Quan
Description
Part Number
Part Description
Reason for Replacement
Invoice #1 005222
Date: 8/30/04
Page: 1
Center: 1
D.O.:
Trans:
Wait:
Labor
Parts Subtotal
Price
Service Requeste,
front end check.. . check everything over. ..wait
EX 00 105 INSTALL MUFFLER Decline 0 - 00
0 1.00 AZ7536 WORLD IMPORT MUFFLER A REQD-NO LONGER PERFORMS FUNCTION Declined
EX 00 10 INSTALL EXHAUST PIPE
6S 1.00 UNIFLEX
UNIVERSAL FLEX PIPE
A REQD-NO LONGER PERFORMS FUNCTION
43.00
41. 95
41.95
84. 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
arc no other warranties issued by Midas International Corporation.
This warranty gives yau specific legal rights; you may also have other rights 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 Jocal telephone
directory or write Midas Consumer Relations, 1300 Arlington Heights Road, Itasca, IL. 60143. 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: $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
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
Oescrlption
Part Number
Part Description
Reason for Replacement
Service Requests,
muffler
EX 00 105 INSTALL MUFFLER
01.00 AZ7536
Invoice #1005223
Date: 8/30/04
Page: 1
Center: 1
D.O.:
Trans:
Wait:
Labor
Parts Subtotal
Price
WORLD IMPORT MUFFLER
A REQD-NO LONGER PERFORMS FUNCTION
15.00
44.95
44.95
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 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 warranty gives you specific legal rights; you may also have other rights 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, Itasca, IL. 60143. 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:
Parts:
Sublet:
Other Fees:
Shop Supply
Subtotal:
Sales Tax:
Paid By :
Check
Pay Ref:
Total:
Paid:
Due:
59.95
$15.00
$44.95
$0.00
$0.00
$0.00
$59.95
$4.20
$64.15
$64.15
$0.00