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1 _ _ I <br /> Il.U[his clalm IrrvoNes a vefride aaidenqmllslan,provlde your�ehiGe Infomiatlon: <br /> . .. . . . Hlafallo. � Make - Model Year <br /> p,�},�r�p � pi�er4L'[ernrNO. VCNdeOwne�'S)(7/dufrrentlromdrlver) <br /> O�wler'slrtswaixe Ca'�O�+Y Phom!Ab. Po/iryNo. I <br /> 12.Names,addresses arM telephone num6ers of all persons hwdved in a wlVleSs to tfNs InUdent <br /> �1AL�A �LQKLr <br /> 06 a.� yT ��n � _ <br /> 4ss 3�N "�2� <br /> 13.Names,addresses and telepiwne numbers of all Gty of Everett employees having knowleQge a6out Ws Incident: <br /> 5�•rrwe Cvr... we�u'/.rt�G4�s ��•�e �,w�" . a�.� yyw �d�Y�.a�t ��a kE� Q�a� I# �1-c tell �ti <br /> r,0�lha - <br /> ---c <br /> 14. Names, addresses and telephone numbers of all Individuak �ro[already hlentiFled in #12 and k13 above who have knowledge <br /> regarding the Iizbitity Iswes InvoNed in thLs Inciden[, or knowledge of the Clalman['s rewltlng damages. Please Indude a brief <br /> d�cripdon as to Me naNre and a#ent of tath person's knowledge. Attdch adMGonal shee[s N necessary. <br /> I5. DeS�ibe the[ause of the In)ury or damages. Eaplafn the euten[of property loss or���Mical,DM/sical or mental Injuries. Httach <br /> additlor�al shee�if nece�ary. t �y ` ` { <br /> SCw[.� 4�[►• t�4�d� hei�f �()G�@��r �O�`�t�' d1wa }�l,�+l,.„��h dnd O'UtF�1J i..�o I,x+t'`LM� <br /> Ah� �4.�i� COO:v. td( �i�r5 ,��G �r�..�l Ut �lCI t4.d_Wlu He�v f40.���fi Ji3o�r..�1� .�,.t C�it�x�5 <br /> I�wlc� �D 4��Ok.a <br /> I <br /> � I <br /> 16.Has thlSlnddent been repar[ed to�v enforcement,safery or security personnel? If so,when and h�whomi <br /> 17.Names,addresses and teleptwne numbers af Geating medical providers. Attach coples of all medical repo�ts and billings. � <br /> 18.�Please attach documenLs that support the claim's atlegatbns. <br /> . 19.1 clafm damages from the Gry of Everelt In the sun of$ �6� _ <br /> 7hls cialm torm must be si9ned by eNher the C1aImaM or on behalf af the pa(mant by an aGorrmy-In-fact wfa hoMs a written power of <br /> � attomey for the Cl�mant,or by an attomey at!aw admitted M praNce In the Stabe of WashingMn,or by a murt-approved guardian or <br /> guardlan ad II[em. � <br /> t declare wder pena0.y of perjuy under the taws of the State af WasMn9ron that tk�feregoirg Is tn�e and correct. <br /> i3�3o'��, �c,��wl# <br /> Sigi q Clatmant Date Place si9ned�cih and state) <br /> rtav.mros ' <br /> o� <br />