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I1. If thu c.�im I�r�olves a veh;de accidect/collision, pmvlde your vehlde Informa[ion: _.._ <br />� - /Mafe No. Alnke Mniel Yc3� <br />f,ibri'sNdnre D:irer's[i:mschb. �e/r,'deChvner(sJ(ldiHcrrnNiomdnverJ <br />p,vnc/s /n5U2nCe Ccny��.vy � Phnnc fJo. Pc.4ty hb. <br />12. Names, addre�ses and telephonc numben of all persois InvoWed In or witnzss to lhis IncidenL• <br />CL1 y:1=�C� �z_� �'�%v1:zY,_�I%��� :�e,:`�' I=IUE>, Yti i';��li��.. '/0�5' .�_l%�.7c`il`� <br />, , �:��.s_ Lr� �.1����1 <br />'��'1�}- F�` _`�--�—��''� 9 _ C ����^�, I::. r� �,,,'_-- -� ' ' `_" - - �-1— <br />13. Names, addresses an9 telepnone numhers of alf Ciry c' Everet[ eniployees having knovdzdge about lhis Incldent: <br />J _ , <br />, �... �� � , �fa� a��I-�s�-:ta <br />�t���l.i<, L���./C_s' _�>i�,��cc •v-� ---- ya5_a� l -�-,�oc c.,r -- <br />14. Names, addresses and leiephone numbcr� of all indivlduels not alre�dy IGentifieA in ,Y12 and �l3 above who have Y.now�edge <br />regarding thc Ga6iliry issucs involved In this Inddcnl, or kr.o��+ledge of the ClalmanCs �esultiny damages. Please indude a bneF <br />descnption as lo tfie nature and eMent of each person's knmvleAge. Attach adAitional sheets if necessary. <br />l5. Describe the wuse of tl�e in)ury or damag=s. ExDlaln the er[ent of property lo� or medicai, physical or menlal Injuries. Attach <br />add1it'ional shccLs If necessary. [� �/ I ,_. <br />Ilrr-i'�n�"A�)cl.�. 1'" �nC� l•� ��.Si�iY1'1L',,6°�� �.Lt.�l�l-'%��.I ; F'1'Q�C_,.Qil.•� � 4(91� <br />LD <br />_Uo-�C�.{_'�����—=�� t�r- _�r <br />I�� <br />16. Has lhis Incident heen repnited lo Iaw er,foicemen[, safety or securily personnel7 If so, when and ;o whom7 <br />- ' - ` --- — �--� -- _. <br />t/. Names, addre:.�es and telephone numUers of lreaUn9 medical pmvideis. Al[ach cop�es of . dl iradical reporls and bilGn9s. <br />tN. Please attach documenls lhat support the clalm's alle9alions. <br />19. [ dam dama9es finm lhe Gry of Everett In lhe sum of #__ _ - <br />Thls clalm form mus[ he sl9nnl by ellhcr lhc Claimant or un bchai( of N�e Clalmanl by an attoioey-In4ad viho holds a �~�dlten powcr of <br />attomey for the Clalmant, or 6y an altorney at law admlited ro prad�ce in Ihe SWte of Washinylor., or 6y a eourt-approveci guardWn or <br />guardian a� litem. � <br />I declare under penalty of perjury under tli: lavts of Uie 5[ate of Wash'ngton that lhe (orc9oing Is hue and correct. <br />�� ���/Z I /� <br />�� Z,_ ` v_ v l'.ti CY �/li <br />� • � e.�� � i� �� _ �� f� <br />S�gn�ture oF Claimant Date Plaze signe (city and state) <br />Rev. 07109 <br />'��, � � <br />�� <br />. �' ; <br />