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il. If thls dalm InwAms a vehide aaldent/co!Uslon, provldeyour veNdc Informa7an: �/" ' <br />l4Ne!No. �Whe Modd Ynv <br />LMAehNamc .--- OrA2r}UavuGNo. Ytlrl.in(M:n�(sJ(NdPtient/romAiNut <br />Ownrr'sfnswancr Canrp.vry FAme Na Pt�YCYN�. <br />12. Namcs, addresses and tcicptnne numhers of all persons Nvoivcd In or wtness to thls InddenL• <br />Ptr'r- unt.i Si-�n.e— er��r, sa.�,,. ..ort��err a te%pA�,c #! <br />13. Names, addresses and telephone numbers of WI Clry ot Everelt emp!oyees havNg krawiedge aboot thk Ir.cldenT. <br />19. Names, addresses anU teied�one numbers of aii Indlvlduals not a'ready identllled In #12 anG It13 ahove who havc knovrledge "" <br />rcgardln9 Ne ILiM1UIty Issucs Invofved In thls Irrcldent, ar kr,owiedge of the (]aimanl's resulUrg damages. P;case Indode a bAef <br />desvlptlon as to Ihe neture and eMent af exh person's kno•r:kdge. AlmcFi addltlonal shects If nemssary. <br />iNCUf� LL_ _I.�pVSLY((�I'i�_•.—_(-IL.IT/�.� R n /Mt�tL�7/N �C/! U/A�P.jfP/' , <br />15. Oew�be Me cause of Me In)vy or daragac. Explain the ex[ent of pcperty bss or medcal, physi;al or menlai In)urles. <br />addRbna� sheets If ne[Cisary. <br />l6. Flas thls Inddmt been reported to law dlPorcemeni, sefery or secudty persnnnel7 [f so, wher� anG lo whom7 <br />y�� . r�,viailPd �JV6�s w�, rn, ��. s� � tin.r s�o�R' tJ Q C�,.tid'�r� <br />y /1tMl <br />P. Nama, addr� es andc leph ne nuntierSof heNlrg m�dl�al ryadders. f.ttach copks d all meJ'.cal r�orls and blltinys. <br />—����'� _ ---------- ' <br />1P. Mer.c attx6 Jw.vtncuL• Ihut :upport lhe dahn's alkgNlons. <br />19. i cNlm dnmaAcs Gom Ihe Gry o( Eve�et[ In Me sum of;J[/J �. �G, ,50�• �d <br />Thls cWim fo�m must he slgneA by eWw the Gaimant ur on 6ehaV al lhe tla'manl by an attomey-Indac[ who holds a wdtten poxer of <br />attorney for thc Oalmant, or by an attrnney at laN• adm4lM lo pra�Ure In the State of Wa�hln9lon, or hy a miul-appmved �uaMlan a <br />q�utXan x11Rem. <br />1 dedare under penalry oF pehury urMer the laws of lhe Stue of Washin9[on Ihat the foregdng Is true Bnd rorrect <br />Date � Placc aigned <br />Rov. OTI09 <br />