Claim by Thompson Finney FortierJ~
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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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 West 13th St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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. S j? P!'~a- ~~~ n ~~',~,
1. Name of Claimant: (~ rnb~r 1 hn -rnn Sn~ / t~0.r~ i ~ 1-~r t ~.e.r
2. Address: ~ `~~Ib ~--bit--S~- ~ ~ # 3
3. Telephone Number jb~ - ~~ 5 - ~o S ~
4. Date of Incident: ~ ~ ~ ~ } 2C~b`7
5. Time of Incident: ~ ~• r5G om - ~•• 3[~ ~m
6. Location of Incident (Be specific):
n ~-`S~ c~ c~~ o~_~gr ~Yner~~l-
7. Describe the 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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1 `., ,. ..~ . _ . _ ,... ~'. _ 1 _ w.'... ,r .qtr r h ~ lam. ~ n a. ~ o lr)~, . r r n lf'
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8. What were weather conditions like?
9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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Damage Assessed By: witch gaherty
Deductible: UNKNOWN
Insured: amber thompaon
Address: 1590 apt 3, dbq, IA 52001
Description: 1991 Chevrolet Aatm CL
Body Style: VanPasa 111" WB
VIN: 1 GNDM 15Z6MI3206296
Date: 3! 5/2007 04:38 PM
Estimate ID: 3534
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Drive Train: 4.3L Inj 6 Cy12WD
Part Type/ Dollar Labor
Part Number Amount Units
15757377 GM PART 210.29 0.3
Line Entry Labor Line Item
Item Number Type Operation Description
1 519820 BDY REMOVE/R.EPLACE L FRT DOOR REAR VIEW MIRROR
I. Labor Subtotals
Body
Add'1
Labor Sublet
Unite Rate Amount Amount
0.3 52.00 0.00 0.00
Taxable Labor
Labor Tax Ca3 7.000 %
Labor Summary 0.3
III. Additional Coats
Total Additional Costs
BIRD CHEVROLET
3255 UNIVERSITY AVE, DUBUQUE, IA 52001
(563) 583-9121
Fax: (563) 556-4482
Tax ID: 42-0400210
Mitchell Service: 915484
Totals II. Part Replacement Summary
15.60 T Taxable Parts
Sales Tax @ 7.000%
15.60
1.09 Total Replacement Parts Amount
16.69
Amount IV. Adjustments
0.00 Customer Responsibility
I. Total Labor:
II. Total Replacement Parts:
III. Total Additional Costa:
Gmsa Total:
IV. Total Adjustments:
Net Total:
Amount
210.29
14.72
225.01
Amount
16.69
225.01
0.00
241.70
0.00
241.70
ESTIMATE RECALL NUMBER: 3/ 5/2007 16:38:09 3534
U1traMate is a Trademark of Mitchell International
Mitchell Data Version: FEB_07 A Copyright (C) 1994 - 2005 Mitchell International Page 1 of 2
U1traMate Version: 6.0.021 All Rights Reserved
Date 3/ 5/2007 04=38 PM
Estimate ID~ 3534
Estimate Version= 0
Preliminary
Profile ID= Mitchell
This is a preliminaryestimate.
Additional changes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER 3/5/2007 16~38~09 3534
U1traMate is a Trademark of Mitchell International
Mitchell Data Veraion~ FEB_07_A Copyright (C) 1994 - 2005 Mitchell International Page 2 of 2
U1traMate Version 6.0.021 All Rights Reserved