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1f,If Ihls clalm Invohu a vehlde xddent/mlilslon,provide your velJde Informallnn:
<br /> fYa!•�h'a `Nakc Flodrl Y�r
<br /> LYMrh. N.mrc � DiNer'sUmnseNo. Ueh.Y/cOwrrer(s)(I/GNcmnf/rtn�drArr)
<br /> On�nr�5�7murencr @rr.pany Phanc No. Ml�;y M1o.
<br /> ��.; ,�� _-..�C��, ���.r ��� � -�_
<br /> 12.IJames,addresses and telephonfnu Ix:rs of all persons involved In or�dlness to thfs Incidenh L�� /
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<br /> ���Ii�s��'__ �-�v�u�'�i����__i���;«���er--�� Iv���:r�nil�.� l/':">..������(�`!.�-
<br /> tv�c���� r'c�ti, 1-�u'd 1 ,;� (-' t��-,�L_c':1 ...,_'/;�<l...c��.�..;k�'�'.' ,
<br /> �- -- - .
<br /> �,�t='l'hf-'�`� 1�1��'c�L4�_'������-�-��'1__'.=�G��'V-1L1v"IC�i \� �L�• ('T/d� !"Ici �/I/�.�lE�
<br /> 13.N�mes,aAAresses and lcicp�ione yn mbers of all City of Everett employces havin9 kno��vled9e abaut Ihis InddenL• �
<br /> - .-�1r'z`'-�--��7rr-`I-f-7;;;�7`�'7,-r.-c�i-�r=/�i��,��� ` r;.-/l�''�rt./-.-1'-i�L,���
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<br /> 19. Names, addmsses and tclephone nu;nhers of all InANiduals not almeJy Weu:illed In ft12 and kt3 a6�vc whn have kno�vledgc
<br /> rcgnrding Uic IIa61Ury issucs InvotvrA In thL IntlCent, o� knowicdgc nf lhc LIal:nanPs resultln9 dama9es. Pleasc Indude a btlef
<br /> descrlption as to the nalure antl extrnl of eadi person's knuwled9a AlWch addlUonal sheels If necvsa�t
<br /> —/(.//`)'1 7/—�('� !. �<' ��i f�� �'i�� .:•,Y1it��
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<br /> -./�'�/�[.�— ' � �%c.�1'1 -' � ? i° 111/_S 1u:,n�! /�.�- _�7-/C'�'.-�/,q-�-
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<br /> ,!"J �?%(/i�?���`�i'�' �—_�%�/i� l i ii(S —��`t� til <' `_ "� � � ��j�jc'(r�C�;� ,._
<br /> I5. De.uribe the cause of lhe InJury or dam�ges. Exptaln 1he ertent of propeKy loss or medical,phYsi.al o�menWl fnJudes. Attxh ���� ���
<br /> addltlonalsheelslfneces:ary. L �f'i���� '
<br /> _�/�')lJ !)%r1iY� S� �l�l,(�' ��cii'/(C�,�.r�� 'll � 1-x' ?% i 7�-/
<br /> - t�?i__//Ci�L .r�•r�; /,�r�!/ � � � ��} Lr�- ,�-' /Jr�.S:�fL.�
<br /> - �� �'l' � <'�� �' '• l.=x�5��',C'_II—�u—i1�� - c,: (=,
<br /> ���'��- � ��;�:1 lr� ��—'iLs�L/.���--C�'>���ff� .������ �
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<br /> ('� � i� / _-,/n`� .�✓) �i. l J C.i t il l! �!-�-
<br /> _1�1i�" _'_�1'��'Fi.____.�� �iL-LL t�c_'<< �
<br /> 1G.Has lhls Inddent bccn mpoded co law enforcement,safery or secunty personncl7 If sn,vrtien ai�d�vhom? l � S , �"I 1 I I `�'p�7(�r�;�J
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<br /> ]7.Names,addirsses and lelephone numlkrs of trml(ng mcdtcal pmWders. AUach rnples of ail medlcal iepmts tiid bllli�gs.
<br /> � �.l� � l�-- — — ---- -
<br /> 18.Plcasc altxh dacunients Lhat suppml Uir.claim s,Iln�atlons. 11�I�� � --� —/— / — / I
<br /> /� �.J��/( � •��)//'�!"Y�.%�/ !
<br /> 19.I dalm dama9es from thc Qry of Evcrelt in Uu:Nm of f�_______._ . _ . . _ ����f ��(� � '
<br /> 7hls clalm form tnust hc s19nM by elthcr thc daimant or on behalf of thc Galman[by an altomr.y-In-fnct�vho Irolds a wdllcn powrf of
<br /> aqancy for!hc Clalmant,or 6y an eltomcy al la�v admlttcd lo pracUce In lhc Stalc af 1Nashington,or hy a court-appruvcA 9uanlian ur
<br /> g�rdlan ad Iltem.
<br /> I��clpr��undcr penalty o'petJury undcr the laws of the Slatr.of Washinginn lhat thc forc9olny Is lme and rorrat. �
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<br /> 7gnT\fure of Clalmant Date Place signed (city and state)
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