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il.If this clalm involves a vehicle acddenV�olllsion,provide your vehicle informaUon: <br /> Pla(e Nn. Make ModrJ Yea� <br /> Oni�e/s Name DN�n's litrnse No. UeAKIe OKner(sJ QfdiKeren[from d�J <br /> Owne�'slruvranm�mpany Plbne No. PoJity b'o. <br /> 12.Names,addresses and tetephone numbers of all persons involved in or wimess to this inddent: <br /> /�r�c� ' �ioaS �DZ GR/D Y Qv� 98za/� Z06�aa1� -/S7Z <br /> , �/Pl �/DZ/ f-�•t'ioaY'� ffai� �J_S-35GS- 97�5 <br /> e P / ' >r �/OZi r',P� 4vP �ZS .7_.3z zizo <br /> 13.Names,addresses and telephone num6ers of all City of Evcrclt employees having knowledge about thls incident: <br /> I3r��v� .�o�/a� 3��o Ce��sr��`�,¢LS-Z57-�'Sz8 � <br /> R.�J`t d�__���! � � < m G� ,CV rr �'�f Wq._yU< i <br /> ��_ _ � <br /> i <br /> 14. Names, addresses and telephbne numbers of all IndivWuals not aiready identlfied in #12 and �13 above who have knowledge � <br /> regarding thc liability issucs Involved In this inddent, or Imowledgc of the Galmant's resuldng damages. Please indude a brief i <br /> desaiption as to the nature and extent of each person's knowlcdge. Attach addltlonal sheets If necessary. <br /> I <br /> 15. Describe the ouse of the injury or damages. Explain the extent of property loss or medical, physical or mental inJuries. Attach <br /> additional sheets if neoessary. <br /> s�orm S�wer Woul�n`�- ��c `� a /� ,f'/,P s��.� ry��es' an <br /> .�7�I�� , ZOl3 So �.I �ie�pirJ��i�,� .�eu,a�E�'2�•��-k� <br /> _Q� n+ r9 V r h.a CP_Y11�h I' G1174�9 S Q r�a� +o,� �C' ! <br /> ]6.Has thts incldent been reported h�law enformmrnt,safety or security personnell If so,when and to whom? <br /> / e��1s��� �/r Ci�� Dis�zo�-_�°1i/ a� 9•oz �°/yl �o Au�...7�1't-ZD-,�— � <br /> � <br /> 17.Names;addresses and telephone numbeis of treatjng rt�edical providers. AtlaG�coples of all mediral reporls and blllings. I <br /> I8.Please attach documenls that support lhe claim's allegaqons. <br /> 19.I daim damages from thc City oF Evcrett In the sum of$�__. <br /> This claim form must be signed by either the Claimant or on behal(of the daimant by an attomey In-fact whp holds a written power of <br /> attomcy for thc Claimant,or by an attorncy at law admilted to praRice in thc Statc of Washington,or by a court-apprwed guardian ar <br /> guardian ad li[em. <br /> [declare under penalty of perJury under the laws of the State of Washin9ton that the faregoing Is hue and corred. <br /> . � , � <br /> ���1 1�11 Y1� �Q�a,� o� �o�� �v�� ��.-� , <br /> Signature of ClaimanE ' Dat Piace signed(dty and state) <br /> Aa�.a7ro9 <br /> !� � <br /> a ����� <br /> � � . <br />