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Claim by Tharp, Evelyn__ _ _ t_ ~~ ~ 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. 13~' 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 DUBUGIUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 1. Name of Claimant: ~yE~,}',t~~ 7Nf9/2/° 2. Address: ~ I pER~ R~ 3. Telephone Number: ~S ~ 3 - S ~a ~ `"~`~ ~~ 4. Date of Incident: ~ ' /3 ' y 7 5. Time of Incident: /~Pr°R°X~ ~ - ° ° ~°/~ 6. Location of Incident (Be specific): ~ Cy~Uor,~°~rt ff ~, 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you baseour claim. If a City employee was involved, give the employee's name.) vp Hac. C}{/zoC R°Ss ~/tiI~F/NG f Tffo~Y/fr J',~/~ SomL T/fii.~G /^' Th'~ R°IPD - .p/G,~`7` SFE /T (i/~7'~c~ S/fE ~.~RS i94h'JGS7` Orv `l~oY of /T, .S'Ce>~/~yE,~ TO h9lSS /T !'YI/1'f~=b J`~ w/~'~' ~~oNT ~N~D"~ SOT tH~ f2/6N7~ h~/1~ w~wZ- ice- A~masT 7'j/~c~T~in /N?~ 7`-/f~ 1~rP.t,~`- /F y-/tcY ,D/!Ja'7 /yea yr ~'EIfT /j E[, Tyr O 8. What were weather conditions like? C oo b ~ ~ i~ /t T ~'~ o ~v 9. Give name and address of any witnesses: ~~~t 10. Did police investigate? (If so, give names of officers.) 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). NQ. 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.) ' 'DES " l21Gff~' Rr~4n r-~ER-,~c~riu~y~~b "~ L.OCvE/t. G'oN7'/tc,~ f9~erh - s-~r~.xr= (,(JE/EEL i9~16 N/I1 ctiT yt~l s. ~S C me C; fl NHS ~o ~/~ - `~~3-~- o ~ 13. What other damages do you claim, if any? NoW ~ 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~-~© '" ~ N 1<Nui:,-N jj T '~ if (S '~ / ~'~? C 15. What amount do you claim from the City of Dubuque? fi~~ Ctf~G ~c Ti`f/ti( 16. Why do you claim the City of Dubuque is responsible? Ti~'t" //~~~ /•' 17nr~~ ~~iS Y3/G E~-~~c/F ~-v S'c~~rE~~~- f~ ~~nso~- - *I~~=n~ cvr=~.c s?-Rr=c~- yc=G/'~~ ol~ TN~`T ~, - ~° cv~t~-~-iNc Sicw r~~ B~A~~~c~a~ 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) ~~ ~ 18. If the answer to Question 1? is yes, have you received any payment from that source, and if so, in what amount? _ Dated at Dubuque, Iowa this l `~` day of ~" E~~~~y 20~. .7-/-{ /s tv ~S F'1 ~,~~d o ~T X012 !'1°!y lviFF C/~noc C~~SS wN~ w~S p2~vrn~6 - ~wNc~c aF eRrz HC~ yyfo~M~~- (Signature) ~i4f~lEG C. C'/Z ~s (Print Name) (Rev. 1/00 & 7/01) €~ a '~' ~ ~iA~Ti~J~d 1,t~~ 44~aJpl~IF~j~~}~~ 3 DATA. TIME A.M REQUESTED BY LOCATION OF VEF{ICIE NAME ~~'.'} PHONE ~... ..........~,~1 ADDRESS . ( /~ ZIP ~ _,~ ~-J/ / MILEAGE S R ICE~IME EXTRA PERSON FINISH FINISH FINISH START START START ~ / TOTAL r/ "'"~L~'~ ' ~ .TOTAL TOTAL YEAR ¢L/CO OR ~ MAKE/MOD DRIVER i~~ ( STAT-Ey- LIC. NO. _ EHICLE LD. NO. / _., l J SPECIAL EGtUIPMENT SLINGiHOIST TOW ~iRE ^ SINGLElINE W1NCH)NG WHEEL LIFT OUT OF GAS ^ DUAL LINE WINCHING FLAT BED/RAMP ~ WRECK ~ SCOTCH BLOCKS START ~ RECOVERY ~ DOLLY LOCK OUT ^ ^ VENfCLETOWED TO REMARKS MILEAGE CHARGE f ~f may-- ,•" ~ ~' ~/~j~/ ,tom / } .~"~ .._ .._ TOWING CHARGE ......................1...,. .. I .,.._ ...__.... .._ ... ..............._T...... .:... /~ ~~ LABOR CHARGE -, I f I.,..,,.1. /` STORAGE CHARGE ~ __;r-- ,~„ . T I ,~ _ ~ i ~ ~~~ r/ •~ `"_'_ . .. /`~ OPERATOR'SSIGNATURE . __ y T AL I 'yy.,,~ I ~._.... /" ~ AUTHORIZED SIGNATURE 47G'Q3 ~_ Road Service PRODUCT 673 F Z ' ~ -TANDEM TIRE R CAR CAR F Dan Driscoll '' District Manager 3435 Stoneman Rd. • Dubuque, IA. 52002 Phone: (563) 582-3696 Cell: (563) 581-0435 E-Mail: ddriscoll@tandemtire.com www.tandemtire.com 'Dubuque East'Dubuque West'Cedar Falls' Clinton' Maquoketa' Potosi Tt^~hiI'~Et~ T I i='.E ;=~Es~~ i~I ?"s"~ c r':' I 3 - :';~ ~`__~ -;"j';1tiE..t*1i=~ta f`.Cfi=1i:? `-_1~ & CAR CARE four Trust With Every Mile `~~ ~1"+? i'hI'I ~'rL; ~:~R t~cct# Ter,ln~ Ship ':!ia .. ~+i_r(,c 1 !11';-I 'rfl=" tTi!=1i'i?"}-1 c -c r JJJ I. 2~ _ -._r _. . _ _ emu- _;_,c~._ G!t±~ Shp D/I:t Ite~s Nlaaber- Description S/W FET Price W1ROt~nt Init'~ - -. - - ~.-, !-°,='~n`~ i?~r-..~a`5 Cry [;~: ~-olJPit"~I~; 'af=,T r: _~ ~1'~ 7! i r, r:.I~r Tt~i'=; TIRE CGR~I(~'=:; N i=rki.04'~4~~ htll_E L.It~iITF:r; WEr~ii?Oi_iT r~Ji=+!'rtt=+PdT`r s A ~~ IF: LEstdE€? +-v+=Ji:1TF: t=iF~t~1~al= _t?t~`:I1~~1'=sl-_h.`t Y~;, ~,r_, ~._;~ f_,i-:. Li}_ii, ~"t.7G1 i t=1~. RR Si='It~aT`'I_E yg~i-k'+~'+1.1'+2f' tJ t:;~., - = i~l~,. _. .- I~I_E~, E{_~t1 f F;t...`~; r=iLTGt'dME~f~lT-=t tl}-IEE}_ THPLlE~T ,-;';=t.'=~~ `=t=,~'=~~ l;j_~;~P._Ji-1 i i t~1t_ INST~=ALL RENf~' CUhdT~~iCN._ i=iRt+i. ~i='it I <f'?. ~`~ ~ ~t'~. ~ ~ 1-1Li1. E:ai~ z i Tf"'~: !_.IEE PrNLt~t`I~~!«'f?~ ~Tti;TIC+t~i-- TEt'I--R}~ i~~ ~~1+3 1 r. 4~+1 DL(). E~"3~{ f-REE MO!_It~t?' I Ps+'~e: "tj 1-t='~ ~Sial....... ` i;'EE D~!t~l PL..i=it.l '~EF:t+I!~E t:1~iTERI(aL'=; - :t<t.:,.-: `,! i ~ l ' ~ ~ : I ~'~T ~_: t_L+'~I~1i ~D I l_c F I St-!T`r' --E 1'=~HT r'iit~_..l r~i:: :ai c' :. ` ~,..!°t. j li I H t Lii_}x ~ , ~ t=hiuf;~?1; -s- _ h,}t-1~J j !7 ~ . _+!'~ 1f~r ~. h~=' ~. }~; Tt}!.~('u {''. F-i t~~Li 1-'i~' T !_ii`u t<: f'~ ~} F'.. `_ ~: - I"i F' f ~ •: 1 ~._ Y,% jam) ~ t _r f•~ a I..j F'•! i'y L! i ~ J t_ t~ L Nationwide Warranty Roadside Assistance Date Tine Dubuque (2 locations), Cedar Falls, Clinton, Maquoketa, Potosi www tanrlPmtirP.~nm