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11,if lhis Ualm involves a vchlde acddenV��Ilsian,providc your vehldc inlmmalfon:_ _ <br /> Flah No. /Nakc McJd Ycar <br /> OrNe/sNunrc [Yrtav4LicensrA'o. �MhleOmncr(sJ(ilCMcrenflrtvnddvaJ <br /> 0lwier}Iruvraxc LompFxry Mmc No. idrzy No. <br /> 12.Names,addresses and telephone numbers of all persons InvoNed In or wltness to thts Incident: <br /> f_?�_�2s-7-9L--.��� t�A�� ¢Z�- ��4z=�di I _ <br /> -�-29J - ¢��— <br /> �S���N - d�c--9?I- 7577 ��Z�7_bS�l2�?S <br /> t3,tJames,xddreues and tclephone numhcrs nf all City oF Evemtt employees having knowledge about Ihls Inddenl: <br /> 14, Names, udAresses and [elephone numbcrs of all individuais not alrcady Idendficd fn Al2 and R13 above who Ireve knowledge , <br />. regardin9 lhe Ilabliity I.ssues Involved In Uls Indden[, or knm+ledgc of lhe ClalmanPs resultlng dama9es. Please Indude a bde( �, <br />� drsrriplion as to the iwture and ezlen[of cadi petson's knowledge. Allad�addiUonal shccls if necessary. . <br /> S5. Describe lhe cause o(the injury or damages. Bxplain lhe exlent af�uopetry loss or medical, physlcai or mental InJuries. Al�ach I <br /> addltlonal shecls If necessary. <br /> D�2-a,�.ca� �n —�Zsx���,R-�A� �7t�- 57azw,_c�2Erz <br /> �ae��?��cdu�,-c--�.-L r��'��/��an_,w.�,.r;s�l�x��uc� <br /> ��r'rN��►?5__�5'��s� L J�.:��(�' �n-� <br /> .�u�I�GD_�-- ��E _t�L�-__—C[f S S c�- f2c=nJz' C�s�� <br /> �--N-��-(o�5eu.'� • --- <br /> 16.Has lhls Inciden[been reOoMed to law entorceinent,safery or securlly{�erwnneR If w,vAien and to wliom? <br /> � s �—Li � �1���.—ilw-'—�—U•���r� � F�a��!")�'�L�� <br /> 17.Names,addresses and[elepiane numbers of lreaun�medical piovfJers. Attach coples of a�l m:dleil mports and billin9s. <br /> 18.Please altach document�lhal suppat the claim's allegatlons. <br /> ]9.1 claim dama9es fmm the Qly oF Everell In[he mm of¢_ ,_ <br /> Thls clalm Porm must be signed by eithcr lhe Gaimant or on behalf of the Clalman[6y an attomey-In-fact who Fwk1s a wnUen povier of <br /> altomey for the qalmant,or by an altumey a[law aJmltted to pracUce in the State of Washinqton,or by a court-approved guardlan or <br /> guardian aJ �em. <br /> I dttla u cr pcn 1ry oF pe�urxler the laws of Uie SWte of Washinglon tlwt lhe fomgoin9 Is Uve and wrrect. <br /> Signature of Claimant �� bate-- Placesigned(ciry and stafe) <br /> Rov.07/09 <br /> n/�/� f <br /> ,L / <br /> ''Y' <br /> �,. <br />