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11. If lhis daim hn•olves a vchlde attldenU�llisiqn, provide your veJdctC Informa[fon: <br />. . . \ ./ . . . PlateNn: � Make � � Male! Vu,r <br />Orlvri's Namc <br />O�vnerS�fns�nteCompany FhoneNa. �K3'l��0. � <br />12. Names, addres5es and tetephone numbcrs of ail persons fnvol�ed (n or wltness N Mls Inddent: <br />13. Names, addmsses and teicphonr. numbcrs <br />knowledge about thls Inddent: <br />14. Names, addresses anA telephone numbers of all Indiv\ld�u� If noC alreaAy IdenG�ed in /!12 and +�13 above viho havc knowicdgc <br />re,uding the Ilabillry Issues Involvzd In this hiddent, f�(nOwledge of lhe ClaimanCs resulting damages. Plea,e Indude a 6ricf <br />oescripNon as to the nature and exten( oF each person�vknowl�lge. Altach additional sheels If nercssary. <br />/ � <br />15. Descrihe the cause of the InJuq� or damages. Fxplaln the extent of property loss ar metlical, pirysical or mental InJudes. Altach <br />addfllonal :heets If necessary. , <br />1I'�/��'L✓VL� • <br />�71c'-t��fL D71�'��/�!�+J — <br />16. Nas lhL^ Incident l�een repoded to law enforcement, sofery or secwiry persunnel7 If so, when and to whom? <br />17. Names, addresses and telephone numhers of treaUng medlcal provlde�:. Altaci copies of all medlnl rcports and billine�s. <br />IU. Please attach documenls lh�f suppo�t the clalm's alleyatlons, <br />i.�-....�i.�..r.r-�- Irf %G.�•— it•v"`r <br />.9. I clatm damages from tlie Qty of Evcrelt In lhe sum of $_ __ <br />atorney for�the Cla mantslor I y an attnmey�at�l, w admltted lo pracl ce In I�he Sta e�of Washln9t n, or by a�,cnurhapprove guard an or <br />guardlan ad Iltem. � ' <br />I�r,iare under penalty of peiJury under Um laws of thc State oF Washln9ton that the foregoing Is true and corred. <br />Rov. 07109 <br />Mr S Mre Rlchard Shaver <br />4936 Dogwoad Dr. <br />Cvcrc[[, WA 98203-31fi'L <br />ied (city and state) <br />i � <br />1 ��I�r� . <br />