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� <br /> 31.lf thls dalm Involves a vehkie arcldent/mlllsion,provlde your vehlcle Information:___ _ _ <br /> P/afc ND. AE�Ac Ffaid Ytvr <br /> I7rAr.��s Nan.r /LArr4 Lltenu hb. I/rhlNe Qvner(sJ(/d'1/r�+mt haTr dMeiJ <br /> Ame✓s/rrsuralrceCmr�uny WxvKNa IbA:yNn. <br /> 1).Names,addrecses and telephonc numbers af all persons Involvcd In or wllness to lhls Inddent: � <br /> 13.Names,addresscs and lelephone numbcr^,of all City of Evemlt crnployces having krw�Wcdge aGout lliis IncidenL• <br /> 11. �'am�, addics:es and telephonc immlx�s o(all individuals not alrcady Identlflecf In J112 and X73 above who havc knowied9e <br /> rcgmdlny the Ilabllity Icaies Involvcd in lhls Incldent, or knolvled�e of Ihc GaimanCs rcsuldng dama9�s. Plmse �nduf a hdef <br /> dc�criplion as lo lhe nalurc and extenl of cach�urson'.s knmvlcdgc. Attach addltlanal shccls If neccssary. <br /> I5. Descrihe the cause of the InJury or damages. Explaln Ihe extad ot propedy lass or medlcal,physlcal or mental InJuriu. Attadi � <br /> additiowl sltcets 1(ncccssary. <br /> �Cr.2 �rtJcr f✓/1 1/_=2 � �Fl✓E�t.� .` _/S I�GK/�✓_ f-' Lc.? i�/+�o _ <br /> _s�-�T> iv �ri Si�n.� i�✓ �.q.(C' /"Je!✓T_, -I•Cao� l�✓G 3c--�' nc��ni✓, <br /> .[�/-J T/f 2 da a� �, l-�/l�.� r/ - _S_,_C L v S�f. ��il.e �"'G--rs ��- �J�-T <br /> --f��n/ I! y(�_E /��G✓�/J _ <<�E C'fi'2fGT C✓A�S 4s�1- ,_�.tliJr..GS.•._� .���L' /✓^ <br /> F� /D O. „ :. �,�5 Y _ ' <br /> 7G.Has thls InciCent Ixen mpaled lo la•N enforcement,safety or sr.cwi[y ryersonnel7 If m,when and lo whom? <br /> 1✓�v <br /> ll.Names,addrec,es and tekphone numLen of trealln9 malical pmviders. A:tach cqiles of all medlcal rcperts and AI'lin9s, <br /> i8.Please atlach dacuments that support lhe dalm's allegatlons. <br /> 19.I claim darnages fmm the City of Everett In the sum o($ � �SD, �J- _ <br /> ThIs clalm fmm m«st be dgned by clthrr thc Clolmant or on 6ehatf of lhc Clalmant Ly an attomcyIndad x�ho holds a wdtten power of <br /> attomey for the f.latmonl,or Dy an altorney al law admltted to pracUce In lhe SWte of Washi�9ton,or by a eourt-appmv�d guardian or <br /> guaidk�n ad litem, <br /> I dedaic under��enalty of perjury uodcr Uie laws of Ihe Stalc of Washin��lon Ih�t Ilir.fon�guln9 L•true aief mrrcd. <br /> /� <br /> /���c✓ .r� 17ixJ �-S"` l3 G-,�eu.71 . CJt1al. <br /> Signature of Clalmant Date Place signed(city and state) <br /> Nov.07/OB <br /> /� <br /> T! `� <br /> I <br />