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� <br /> ; <br /> � <br /> 11.II thls dalm involves a vehldc acddenVcolll;lon,pmvlcle yourvchido Infarmatlon: <br /> /'lafr.Na Muke p:adel Yrar i i <br /> OrAxrYNanic DiAri'tLkmsrNo. �r�5/dcaimr�(s)(JdHurnf/rtHidA�rrJ I <br /> O;w¢rfrLnurunmCompairy �PAoneNo. PofhyNo. , <br /> � 12.Names,adAresses nnd teieryhone numUers nf all persons fnvolval In or vAhicss to thls IncldenC <br /> � l3.Names,addresses and tclepiione numbcrs of all City of EvcrcU employees havin9 knavledge about thls Incfdontt I <br /> Sq, Names, addresses anA[clepiiono numhers of all InAlvlduals not already Iden011ed In It12 and N13 abova who hava knnKiedpe I <br /> regarding thc Ilablliry Issucs InvoNed In Ihls hicldent, or knowledge af lhe ClaimmCs resulGng Aamages. Wease IncluAe a bdef <br /> dexri�iton as to Ihe nahire anA eNmt o/each person's knowledge. Attar.h aAdlUonal sheets If necessary. <br /> 15.Desttl6e Ihe wuse o(lhe InJury or damages. f.xplaln lhe etten[oF property Inss oI Inediol�phydcal or menl.I InJurles. Altach � <br /> � addltlonal shects If necessary. <br /> Due to henvv rainu an hhe ;.9Gh oC Auau� qWt'�k,eg�n lo b k� Ch• ��h chc mrn�x tollet. <br /> . Tim aaCcr From Uie tailnt Gonkod thu carpoto und Ganoboardn ln ell amac nurrounding Cho <br /> bathroon. Rxpenoan vcre incUnred m dry our enrpet:x, drhmnidlty tho buildln9 to pecvent mold <br /> . ga'owCii, and r.lr.an Che aEExctod Cazpeta <br /> 16.Has lhls Indden.Imen reportal lo law enloicem��it,safety or secmt�y persomiel7 lf so,whev and towhom7 <br /> � 17.Names,addmsses anA teleplmne mimbers o!lre3Ung inedical provlders, Altanc�opks of all medlwl mpoits and blllings, <br /> . IO.Plcascollacl�ducvmenislha[sm�w�tlhr.dnlinkallr!}atlous. --� -�----�--------'------ <br /> . 19.�-lalm damaAes(rom thc C(ty of[vercil In the sutn of; 2.93 7.4 0__ <br /> � Thls dalm form must be sl9ned by clthr��Ihe Clalmnn[or en bchaif of the Clalmant by on altancy-indad wL•o ho1Js a H�dtlen power af <br /> � aetorney for the tlalmanq or by an attnmey af law admilled lo praUlcn In lhe 51ate nf\V,xsltlnglon,nr hy a cnun epproved puardian ur <br /> - guaMlan ad Iltem. - <br /> : 7 dttlarr.under penalty of perJury und�I m�lawso Ihe State of Washln9lon that the finegoing Is live and rnm:ct. <br /> �J)�L�2��6/,J}�-,y'_ �J� __..,, 09/13/7.0:1.3 �crett, WA <br /> � Sign�af Clalmanf' pale Plnca signc�(city and stato) <br /> Rav.0716d <br /> ���1_ I <br /> '.. <br /> L'�' n <br /> i� ' : <br />