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Claim Bauer, Stephanie 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. 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: Stephanie Bauer 2. Address: 731 Brookview Square ` 3. Telephone Number: (563) 583 5449 4. Date of Incident: March 31,2005 5. Time of Incident: About 12:30 P.M> 6. Location of Incident (Be specific): Across the street from 900 Cedar Cross 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.) As I drove along the road, my front tire (passenger side) ran over a loose piece of road, kicking the piece up and hitting the underneath back part of the van. 8. What were weather conditions like? Clear 9. Give name and address of any witnesses: Yes, Officer Schmeichel 10. Did police investigate? (If so, give names of officers.) No 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). 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, Damage to under carriage. Refer to "Wilson Brothers Statement." 13. What other damages do you claim, if any? 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? $108.35 16. Why do you claim the City of Dubuque is responsible? The City is responsible for maintaining the road. The road hazard was not marked. The loose piece that damaged the van was not evident by cars driving over it. 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 8th day of April , 2005. /s/ Stephanie Bauer (Signature) (Print Name) (Rev. 1/00 & 7/01) --- (j;~ CLAIM AGAINST THE CITY OF DUBUQUE;--IOWA 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: 0t~ I€___ "DaL-t -e..r 2. Address: 13 to (001<. V (~ ~()..^- or e:.- 3. Telephone Number:C~lo'~) ~~(S~.- OJ 4'-\9 4. Date of Incident:--fY\a ((-A,\ ~', ~ V 05 5. Time of Incident: Q\:)OU -,\- )OL~ 30 9.m' 6. Location of Incident (Be specifiC):__~r06S ~e... V+ce-e+ +;-c) yY\ 900 C .fcla ( 0005> ' 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give I full details upon which you base your claim. If a City employee was involved, give the t: employee's name.) A6 :;t:; rl-ro~:f' CA.\bnf6 ~e f~ )l'V\l) ,.(i-nY\:t: ~ _-hff, C\J~~~ ;'\0-e) ft-Lrl 01)<< cA. I~-e, pl-ece of ro~t:t, Kl4-\n~ ~e ~re(--e 'ur U\~vi~he \Jrde("y\'f~ I \oCl~ ~VL \ t- of' ~e \lOJI1 , 8. What were weather conditions like? CJ-ea . (' 9. Give name and address of any witnesses: 10. Did police investigate? (If..so, give names of officers,,) () ~\~CJ' -- ~ -o('J-1YY\J)iC~ 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). ;JU 12. Was any damage done to property? (If so, describe property and the extent of. dam~ges. Attach estimates of damages or describe basis for ascertaining extent of damage.) \~0-1)~~g>, -to ~~ Ctl(rlCU}f" ~efu-tv . W\\So(\ O(o%e(s S\-rA~~'1 13. What other damages do you claim, if any? --..-.-..... 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.) rJU 15. What amount do you claim from the City of Dubuque? 4>'~'3:J '"'\1\~ c~~ 'i? r e~fOl'l $\ bIG +Ur 16. Why dOJOU claim the City of Dubuque is responsible?fY$A...wy+{)\Y\ \n~o fCX\ols.... --r\Af. ",va ~~('d $.X.t~. no-\- \fV\Ct '(~.'eq I '\he \ose pIece . ct.-\ dcL.mL.\~ct --11r\'t~ va...t\ V-X'-t"? (\0\- -e \l0\qtt \o'j C (::.c r 7 d '(" \V Hf\~ (:) '-1€..\ 'rt- ~ 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) } AD "" 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 t~tfL. --tJ0 day of :.-) c , 20 O~ {Signature &-ephCW1ie rnilr:l (Print Name) ~. ,. -.... \-J (Rev. 1/00 & 7/01) 90 KENNEDY RD. DUBUQUE, IOWA 52002 (563) 583-5781 1-800-747-4221 ODGE DUBUOUE DODGE! ~ Gr:RVfCr: fPVO!Cr: CUSTOMER COpy PARKER BAUER CUST# 3750 731 BROOKVIEW SQ RO# C516703 PG 1 DATE 4/01/05 - 4/01/05 POi WRITER 308 APPROVAL 308 TAG # 449 DUBUQUE IA 52001 PHONE: 583-5449 /563-000-0000 -------------------------------------------------------------------------------- OWNER 3750 UNIT# TB363362 DELIVERED: 4/10/96 VIN: lC4GP54R4TB363362 GVT.rJR: 6,000 1996 CHRYSLER TOWN & COU CURR MIL 132,817.0 TRANSMISSION: 4 SPD ENGINE: 3.3 6 CYL -------------------------------------------------------------------------------- (Cl 1. CONCERN: LUBE OIL AND FILTER; CK ALL FLUIDS AND SEASONAL INSPECTION CORRECTION: LUBRICATED CHASSIS, CHANGED OIL AND FILTER, CHECKED ALL FLUIDS AND PERFORMED SEASONAL INSPECTION MENU PRICED LABOR LABOR: 001 PARTS: 1.00 5281090 1.00 OIL5 MISC: COUPON 7.75 * * FII..TER-ENG 5 QTS 5.95 7.45 5.95 * 7.45 * 3.:W- SUBTOTAL LABOR SUBTOTAL PARTS SUBTOTAL MISC 7.75 13.40 3.20CR C) 2. CONCERN: CK FOR DAMAGE TO REAR UNDER CARRAGE,CUSTOMER WANTS SHOCKES R EPLACED CORRECTION: REPLACE REAR SHOCKS AND DAMAGED SHOCK BOLT SUBTOTAL SUBTOTAL 49.00 "* I 56.00 .: I 3.35 :; LABOR ----49"~-mr-- PARTS 59.35 LABOR: PARTS: 2.00 1. 00 BA32290 REAR SHOCK 6101557 "'- - BOLT 28.00 3.35 TOTAL LABOR TOTAL PARTS TOTAL MISC EXPENSES 56.75 72.75 3.20CR THANK YOU! .' STATEMENT OF DISCLAIMER The factory warranty constitutes all of the warranties with respect to the sale of this itemlitems. The Seller hereby expressly disclaims all warranties either express or implied. induding any implied warranty of SERVICE DEPARTMENT HOURS merchantability or fitness for a particular purpose. Seller neither assumes nor authorizes any other person to assume for it any liability in connection with the sale of this itemrrtems. MONDAY - FRIDAY 7:30 a.m. - 5:00 p.m. CUSTOMER SIGNATURE 90 KENNEDY RD. DUBUQUE, IOWA 52002 (563) 583-5781 1-800-747-4221 ODGE DUBUOUE DODGE ~ Gr:RVfCr: rr,I\fOICr: CUSTOMER COPY PARKER BAUER CUST# 3750 RO# C516703 PG 2 REPAIR ORDER SUBTOTAL TOTAL ENVIRO PROTECT DISP *SALES TAX REPAIR ORDER TOTAL 126.30 2.45 9.24 137.99 COPY ONLY THANK YOU! STATEMENT OF DISCLAIMER The factory warranty constitutes all of the warranties with respect to the sale of this item/items. The Seller hereby expressly disclaims all warranties either express or implied. indudin9 any implied warranty of SERVICE DEPARTMENT HOURS merchantability or fitness for a particular purpose. Seller neither assumes nor authorizes any other person to assume for it any liability in connection with the sale of this itemrrtems. MONDAY - FRlnAY . . ...-- . . CUSTOMER SIGNATURE 7:30 a.m. - 5:00 p.m. v )