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tl.lF thls daim Involves a vehide acdd�tJmllisbn,provlde yaur vehide information:!"�,.�_� � I, <br /> P/afeNa. AFiYe plodr.l YeN '. <br /> _ — —�'��� . � <br /> Odm�YName �crnScAu. VM.4Ye0wner(sJ(JdJhvrnt(romd�iver) i <br /> O�.�rance rnny.�� PAone Na Padky�h. I <br /> 12.Names,addresses and[ctcphonc num6ers of all persons Involved In or wttness to this IncfOeM; ' <br /> C�c�� r����J 7` '�`' C LJ41 M!'�h�T 5 r-q N�r ��! • <br /> 13.Names,addresses and teleDhcnc numbers af all City of Everc�t emp!oyees having knowledge ahout this Incide it: 1 <br /> ���:I�cTT t��t�LiC, WU�eKs D�Pr_, �f2�-�57 —'B��rrr�� $- 3o-a�� ( 3 , <br /> nt� Gn1��-o� �E ���r G�N i�f�o ��c���t����r�1��.�GrIT <br /> C�•a����� uN -r n-r s�-r�t� �a^/ , <br /> 14. Names, aadreses and telepl:one numbers oF all Individuals not atmadY Identified (n N12 and #13 abave who have knowledge <br /> iegardlnp the liability izsues Invotved in this inident, or knowledge oF lhe tlaimant's rewiling dama9es. Plcase Indude a bnef <br /> desciption as to the naNre and eMeM of each persods kim�v�edge. Attarh additiowl sheets If nccessary. <br /> �'KEd��," �LPIaE C���hAJitJC� �+-�?ESTo�AT10N �{�:� "'�-�-'7��� , `1-l-�L�. <br /> uDhJtp'� i'�tROC�F� a15Asr�rc 5Gl� l�C,�-f�5-337-�.�. -l-aJ13 . � <br /> ��-1 �K:-r�NS�oM�,4r.�r�s �RE_i�lnus-r� ��C�RTs n1 A-TeK- DA�+�ACa� , <br /> I5. Deuribe the�ause of the Injury or damages. Explain the exten[of property loss oc medlcal, physical or mental injuries. At� �� <br /> additiona{sheets if neceszary. <br /> oN� ��lasZMcn1T -rL��>�� �✓rn.� APPr�6y , �" D,�I-�rJ u�R�r'�2- Tlth� <br /> cuSN�� u� n �AS�r�� T �P�r , riai5 ncc�.in��b Du�ING A DEU,IC��J <br /> P-A•�►J STU�M �UE '� 'CN T U��Q.Vt/NELh�Et> C/EI�ET'f's STD�M DFAt�I �- �i,t/E,� <br /> yI��YEN� 0----zR i7 : 1=A�lrL�( �M �AQpG'(f,JAs COMPGGiGLy S!1"lur2�-r�� <br /> "��LEtiI�D cl►JSALJJ�L�Af3�-� ��P�S�U� la MOt.p �-n�irlGYt� 155(,c�S , <br /> 16.Has this inddent been rcDortM!to latv enPorcemen[,safety or searity personnel7 If so,when and to whom7 f <br /> - Tv �— __. �.�_ I <br /> � <br /> I <br /> 17.N-��m/�es,addreses and telephone numbers of treatln9 medical pmviden. Attach copies of all medical reparts and btllings. �, <br /> N 7"1 - ---' ---. _....---- --- --- I <br /> 1tl.Please attach documentt that support lhe clalm's allcgatlons. ��TT{�C-«L%� <br /> 19.I daim damages from the City o1 Everell in thc sum of� '�`�'"�'� '`5 <br /> Thls daim fomt must he slgned Gy ci[her the Claimant or on behalf of lhe Oaimant 6y an aUnmey-tn-fatt xho holds a wrttten po�vcr of <br /> attorney for the Clalmant,or by an atlorney at law admitted tn pradice in the S�te of Washingron,orhy a cnurt-approved guardfan or <br /> guardlan ad I1Cem. I <br /> I declare under penalty of pehury under the laws of the State of Washington that the foregoing Is�rue and correct <br /> t <br /> CCo�, � ��u, 9- B-ad[3 �-+�w�� Cc.�A-� <br /> Si ature of Claimant Date Place sfgned(cfty and state) � <br /> Rev.07109 I <br /> ��I 'I ''I <br /> �• ��,. <br />