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� � � - �- 1 L If thls clalm In•ia'ves a ve1,Mc.a!dc�V���'��.�ti`�Ca ycur vchlde In(o n,11p.i: <br /> � PblrAb. N�e P(q9N -Yevi <br /> O,bc,Ynune � � Odrvrf/�m,*db. -' � VcAiieJ.:ner(s)(1dd/rrtnNmmdA�rJ <br /> '� G1mer'slnwmrrcc�amyanY -_-�'_--�- N%ancNa .�.+— N:KyNa .���.----- <br /> �, 1Z.fJamcs,addres;es and tctr.phoie nure6ers of eV pcnons involveA In or wdaess to thi:InddenC �I <br /> JciG(2 C +�.�5-7.SS�Co�/��'k, <br /> Ca,S_5�_�1,.�''���7_ 2)�'1-�'e. [��.V�P.St";�{— .. <br /> c�a,,r�'�Ki3��-�'-ro>;e.�`---�''��--�"-y�= A'^e�.--�vc rn.ti� �t.a�-a 5 s_[��/g� <br /> 13.Nsmes,addresses and tcl^_D��ono nundxr of aV City o!Everctt ertiployces hadnp knnxiedge.abnul!h6lnddenL• i <br /> t4. t�ames, addresms and ldephone numbers of all Individua!s no[a'rearJylAentlOed In k12 and N13 ahove who have knoxiedpe <br /> re9arding lhe Iiab!Ilry Issu=s Involved In Ihls Incl9ent, or knoa�tedge oF Ihc Oa!manl'S resultlnq damages. Plcaso Intlude a b�ief <br /> descdpUon as tu the nature and oatent oF each peitads kno7de�e. fdtach ad�U�nal sheeL^it necessary. <br /> T I <br /> 15.Desvlbe Ihe wute of U�e Injury or dunages. Explaln th^edent of prop:ity loss er niediral,MiYslcet or mental INunes. Attach I <br /> � additlonalsheelslf�ecesszry. � <br /> � d�..Gu_�tz v�'-�ciV -�'cli v1 ' L1"�Iv�f+=l N. __���`-'�9_�1, . -2.veriiYtc� <br /> . . � u5�" ,2�--�.ih=.�Tc9.%i2u�,.�-���uc,�r_11n'. C�j._ r��' �JdY <br /> Wl,y —3 ln��ca�c_ - � 5��y1-'rt���vl� S�rn-cv �oorin�C� <br /> � ro _- .G��e__�'_�f//� ts �'r�e�cr�'t11�f1�_�JC1a1S crvy�lw_. �rjy`�e.luc� <br /> ��-�- - —• --.. <br /> 16.Has this L¢Went heen rcported to law en(orcement,sa(ety ur sccxidty personncR If su,when and co e+hom7 � <br /> _..- <br /> 1%,iJames,addresses and tcephnne numbcis of creatln9 medlral provlticrs, ntLxh mpies of all mcdical reports and binings. � <br /> . �-- ----�----------'-_"- -- � <br /> 10.Plcasc attach docvments that support thc daim's ullegallons, <br /> 19.I Ja6n dcmapr.c frnm Uw City of E-.emtl In Ihc sum of���-���l�1Pi^--����''Q"" <br /> 7hL dalm(mm must be slgned by cither lhc(7almant or n�bchalf o(thc Clalmant Ly an attorcey1mfaR who helds a wiilh:n power ol <br /> attumcy for lhe Cla!mant,or by an attomcy at law adm'�.tted to Dnctl:e In lhe Stale of NJashln9tan,ar hy a cai�rt-approvrA guar6an ar <br /> quard!an ad Illem. <br /> 1 dzc4ve under penalry of perjury undel Ihc laws of the Slate o(VJashington Ih;,[thc Faregoing I:tmr.and mrred. <br /> }y', , 11,C'h-n�an1/____�_-l.��"'�� _�?�e��EG9,� j.[1Q._ <br /> Siynatur� f Clalmant Date placc signed(dty a�etote) <br /> Nov.DiWB <br /> .. ._ .. _ . . . " l \ <br /> ���/ <br /> _ <br />