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Claim Devenuta, Deborah S.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: Deborah S. DeVenuta 2. Address: 1206 Rhomberg 3. Telephone Number: 563 583 2617 4. Date of Incident: Feb. 12, 2002 5. Time of Incident: 4:05 P.M.0 6. Location of Incident (Be specific): 966 Rush St., I pulled into a parking spot which had a full street, when the tire when the tire went and caved in the road. 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.) I pulled into a parking spot and the street caved in, casuging the passenger side tire to cave in the street. When I got out of the car the car began to sink and turn on its side. I called the police, tow truck and the City. 8. What were weather conditions like? Good 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) Yes, Strumaerger 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.) No 13. What other damages do you claim, if any? The subframe of care, time lost from work and tow bill. 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? $393.53 16. Why do you claim the City of Dubuque is responsible? Tow truck Bill $37.10, Missed 3 1/2 hours of work @8.98 = 31.43, to fix subframe $325.00 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 13 day of Feb. , 2002. /s/ Deborah S. DeVenuta (Signature) (Print Name) (Rev. 1/00 & 7/01) ~AINST THE ~QUE, 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. 2. 3. Telephone Number: 4. Date of Incident? ~ t ~t ~O ~)~ 5. Time of Incident: '~ ~ 0 ~'~Y~ 6. Location of Incident (Be specific): (~ ~9 ~ 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 e~ployee's nam~e.) , , 8. What were weather conditions like? ~ Oq::r-O~ 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) 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.) 13. What other damages do you claim, if any?-~o ~ ~, L~c~_. ~c~ ~ ~ 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.) 15. What amount do you claim from the City of Dubuque? 16. Why do you claim the City of Dubuque is responsible?~~' ~c-~C~ ~;[~_,~q. I © ~ 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 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, Iowa this /~ day of (Rev. 1/00 & 7/01) ¥! 'e nnnn ,20o3. (Signature) (Print Name) REPAIR ORDER PRO CARE AUTO 1020 CEDAR CROSS ROAD DUBUQUE, IA 52003 (319) 582-9858 HOURS: MON*THUR~ 8AM-SPM FRI 8AM - 5:30PM CLOSED WEEKENDS ASE TECHNICIANS DEBBIE DEVENUTA 1206 RHOMBERG DUBUQUE, IA 52001 582-2617 R/O #: Name: DEVENUTA Date: 02/13/2002 License #: 860AWA Make: FORD Model: TAURUS 3.0 Year :91 Mileage: 103929 RECOMMF, NDATION5 ANI) TECHNICIANS NOTES SUBFRAME WAS BENT DUE TO DROP IN STREET $325 PLUS FHDDEN DAMAGE IF ANY LABOR PARTS SUBLETS SHOP SUPPLIES SUB TOTAL TAX TOTAL .00 .00 .00 .00 .00 .00 .00