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11.If thls clalm Involves a vehlUe accldenVeol�lsion,prov'de yourvehide Informatlon: n�A <br /> PlaM M1'o. Make Pkdel Yerr <br /> DiivertNa:ne aivei's[4rssrAb. V�+do(l�vner(s)(i/d?Avrnt7romdnva) , <br /> P.vner'slnsvra,�aCany.vnY Phoneh'a A+Iq•M1b. — i <br /> 12.Names,addresses and tdephone mm�lr_rs oi all persons involved in or witness to this Incidenh <br /> ' n /� <br /> 13.Names,a9dms,es aiW tetephone numL•eis of all Gty of Eveiett employees havtng knowiedge a6outihls Incldent: <br /> C'cr rldn Gct�.,-. � i�d 'u �c.v`H,weSF <br /> P,� ; c.J k, p --- -- <br /> 14. tJamec, addresses and telephone numSers of ah Indivlduals nol already IJenlifled In #12 and lt13 ahove who have knoK1edge <br /> regarding the Ilabllity Issus Involved In this Intldent, or IcnawiCdge of the ClalmanPs rcsvlting damages. Pteaze �ndude a bitef <br /> deurlpUon as ro the nature and eatent of each person's knowledge, nttach additlonal sheets If necessaq�. <br /> ----------- �I <br /> I5.Descrlbe the�ause of Me In)ury ot damages. Ex0laln Ihe�[ent of prapeRy loss or medical,physlcal or menlal InJudes. Atuch I <br /> additlonal sheets�i�f ne�cesury. y, � /�,�� <br /> ._S�Uf ��'i i�1 Se E O Ir*fU l f-� �}:,�`CMC�lI <br /> ioL n c l (-�-uQ. F}1( CC✓Oe <br /> J��I� ca..6�'ne� _ . q.no(_ n e be vt'r�m ed <br /> ..��t'r��5� c nPPnted�� l�¢ �'��H�-• <br /> 16.Has tlils Indden[ybee—n repo�t/te�d�lo law enforcement safety or secudty pecunneN if so,wh/en�and lo whom7 <br /> ---'_'— iC� 1f''�����C. �A�Q(�S \�O�/+r'��_�VI�� � 1�l/��E <br /> t7,Names,addresses and telephone numbers of treadng mediwl Drovlders. Attach copies of all medtcal reports and blllings <br /> 18.Ptcase alWch dacumenh lhat support tha da0n's allegatlons. � <br /> l9.I Uaim damages from Ihe Ciq�af Everett In the sum of q._T Q�_,._. <br /> Thl.s ciaim form must he slgned by clthG�the Claiman[or cn behalf of the Clalman[Gy an aHomeydn•/acY•Hho holds a wdtten power of <br /> attomey for the Clalmant,or by an attorney a[Imv admiMed ro prauice In the StaM ot Washinglon,or by a court•approved yuardlan or <br /> 9uardlan a0litem. <br /> I declam under p alry of perJury under the laws ot the State of Washington that the fore9oiru�Is true and correcL � <br /> 1� I <br /> ll -31-L3—_ E���e-F4- y�A._--- <br /> Sipnature of Clalmant � Date Piace stgned(clty and state) <br /> Rev.O'108 <br /> I <br /> �� <br />