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It. If this claim Involves a vehlde accldent/colNsion, provide your vehicle Information: <br />Pete AO. Nah• "Wq YM, <br />12. Names, addresses and telephone numbers at all persons ved In or witness to this Incident. <br />13 Names, addresses and telephone numbers of nil City of Everett employees having knowledge about this Incident: <br />14. Namt .^�.esses and telephone numbers of all Individuals not already Identified In 012 and 4113 above who have knowledge <br />regarding i' :e rbillry issues Involved In this Incident, or knowledge of the C almant's resulting damages. Please Include a brief <br />j descriptionst•, the nature and extent of each person's knowledge. Attach additional sheets If necessary. <br />15. f escriuo 1. a cause of the Injury or damages. Explain the extent property Ia or m - .:dl, ph' ,.J or mental ;udes. Atta:h <br />addiUo al sheets If necemry. <br />ItJQ�'f/ G32J <br />i roe? <br />i <br />16. Has this incident been reported to law enforcement, sefety orsecuriry, personnel? Ifso,whenandlowhom? <br />i <br />17. Names, addresses and telephone nuIDbers of treating medical providers. Attach copes of all medical reports and billings. <br />i — <br />18. Please attach documents that support the claim's allegations. CA) <br />i 1g. I claim damages from the City of Everett In the sum of It — ? <br />3 <br />r This claim Conn must be signed by either the claimant or on behalf of the Claimant by an nitomyyIn•fact who holds n written power of <br />attorney for the Claimant, or by an attorney at law admitted to pmcllce In the 5mte of Woshinglun, or by a mot -approved guardian or <br />r guardian ad lltem. <br />n <br />.t 1 Jalorc under oael of perjury under the laws of the 5 a Nashingron That the forcgoing Is toe and corrttt. <br />_ _ 9�3 i3 fi��G��IJ�t..• <br />SI aturo of Clalmani Dato Place signed (city onJ stato) <br />nnv, Ti" <br />