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il.If lhis claim Involves a vehlcle a¢Ident/colilslon,pravlde yaur vehlde�nformatlon:_ <br /> qaknn ns�er roadd rmr <br /> DAve/sName DiAt/s[kenreNa ✓MlHeOivner(sJ(llGJkrcM/icmdiArr) <br /> Oime/s fnwnixs[bmpurry OAarc/!a Ca7ryNo. <br /> 12.Names,addresses and tclephone numbers of all persons InvoNed In orwltness ta thls Inclden[: <br /> 13. ma,address�s and tdephone numbers of all Oty of erett employea havin knuwtedge abou[fhls Inddmh <br /> —� � <br /> 14. Names, addresses and telephone numbers ot all Indivlduals not already IdeMi,led In fll2 md X33 above who have Imowledge <br /> regarding Ihe Ilablltty Issva Invotved In MIs Inddent, or knowledge of the Qalmant's rewtdng damages. Plwsc Indude a btld <br /> desniptlon es to the naNre and extent of axh persan's�mow1 Qmdi ad0ltlonal:hee��^If,y^eassary. <br /> � �✓ (l.N L <br /> ( <br /> �I11 � - <br /> I5.Drscrl6e Ihe wuze of Ihe InJury or damagas. EKpla'n tha extent W praperty loss or medl�l, physlul ar mental InJurles. Attacl� <br /> addMonN sheets M ne�sary. ' . l ' A <br /> � � W` <br /> Z <br /> � • <br /> ��th s hddm betn r�rted lew f�safety secud Pcrsonnef� If so,when end to whom7 <br /> ��L R/3o �.n�� A��v. <br /> 17.Names,addressas and telephone numbers of treaUng medlcal pmvlders. Attech coptes af eli medlcal rcports and blllings. . <br /> I8.Please attadi dauments tl�at support Ihe dalm's allcgallans. <br /> I <br /> 19.I dalm damages from tlie Clty of Everett In the sum of y_ <br /> Thls deim fortn must be slgn�d by clthtt Me Oeiment or on brlmlf of the Oalmant by an attomeMlndaR who holds a wrfttm pomr of <br /> eltamcy for the tlalmant,or by an aKomey at law admitted to praRice In the Stale of Washingtan,or by a court-approved guardla�ar <br /> guardlan ad IIMm. <br /> 1 dednre under penalty of perJury undcr Ific laws of the Shte of Washington thatthe foregoing Is Wcand mnect. <br /> /��.�����e gl 8//`3 �ii� ��/,� <br /> SiynaEure of Gatm�nt D De Piaoe slgneA( and staDe) <br /> Rov.07108 <br /> /• " '� <br /> � 1 �.� � <br /> ..� <br />