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i <br /> 11.if this clafm Involves a vehide ecddent/mlllslon,pmNde your vehldc Information: � <br /> PlamA'o. Ma.(t Malel Yc�r <br /> Ori�rr'sName UMrr's(lcenseNa ^YNlldeOimei(5J(ildprefrntlmmd�ivP�J T <br /> � <br /> Owncr's Insumnre lampany phoac No. A�liryNn I <br /> 12.fJame„addresses and telephone numbers of all pe ns Invalwd in or witriess to thl,Incldent: <br /> e��e�c� ,,_��J��. �/�S-�.��-31g7 <br /> 13.Names,addresses and telephonc numbers of all Clty of Everett employecs haNng knowledge about this Incident: <br /> 14. Names, addresses and telephone numbers of al1 Indlvlduals not already Identlfled In Al2 and B13 above who have knowledge <br /> regarding the Ila6ility I�ues Invo!ved in thls InUdent, or knowledge of the Claimant's rauiting damages. Please Include a hrlef <br /> descrlptlonI as to the nature and extent of each person's knowledge. Attacfi addlticnal sheeLs If necessary. <br /> CY�r�S ��hie�S SY P�a�ecf �lLiy���r..E� BAA All �ily �ui,�v����.-�, <br /> ___Q�--3�i0•'�63"�53c7-----C riSQ QI'i[t__Co�(f�tic:�w-)_ Ae!" — <br /> I5. Describe the ceuse oF the InJuI�or damaa s. Ezplal�}�he extent af propetty loss 9�r�medlcal, hyyceI�or m el InJurl0s. qttach� <br /> additlonalsheetrifnecessary. � I,�G�Ptf Q�Qn�� �}w JOs�k.YS 4e W«"' o�� �i��knY �D��r� pl✓✓•�-� C'['C<K�� <br /> � � n e,� e1 �f �. Q 6 A{)1��71�� c�� <br /> vJ:irs G.`^� C J Y uTd1 f ��, � �aafr. <br /> —__a�sb._ _o�'�w��a�I ��f��•�-- -- <br /> � " O '�IQ�.�_�����. <br /> � w,� ,�, ��u. �, � s�•/ .t��P !J, ��� fo c% � u �h'f <br /> _--r��,5,y_.__1��rh,s__'��CJl� no/ ,� e�ca.�e= d_ + �/a,hG, � <br /> -d6.Ha;tI�H-Melden/-6eertre7r e o aw e t;,afetyor-seeurity�per�P aeW�P�a�dtolvhoml--- I n <br /> �uw� � !'W�.1•• d ntI%, p. �`s-f J Y lvs��s:_ � •� Prci�e�e �'/�1 GnN �Jo�'s I <br /> �1T:Name;adtlnresse,�arRttctephon/cncmibeisoHr.vtlagm�dlwl�rnvidus_9ttact�cople/snf.all�medlraLreoorts and blllingr. �rjy /°DI,v� j <br /> 1V�llYR' S'Jt�rtr� _�/��_�J7 ._/S //1 CU),.n�v}G�_ /L7 '�f1.�1��1�' ()J'T .�ltJ✓Y��" I <br /> --- '/ /� / T - '-1'--n / <br /> �--- --11 _flC' _'�a c f'7_ G. _[!/4�.Y➢l__,/1.J�r�C'r_—Ct1_tl'._ ^i•t �41v1'A��.. k�^�Tc''��r� M`� <br /> , (1 �1 + —�--�� / <br /> -----��`�n�'� -+„�,���vn._�__ lC.��.,y__._. I <br /> S6.Piease attach documents that support the clalm's alle9atlons. <br /> 19.I daim damages from the City oF Everett In thc sum of$ _ <br /> Thls dalm(orm must be stgned by either tlie Clalman[or on behalf of tlie Claimanl by an attomey-Imfad who holds a wri[ten power of <br /> attomey for the Clalmant,or hy an attomey at law aAmitted to pmdice in the State of W+�shington,or by a couR-approved guardlan or <br /> guardWn ad litem. <br /> I dedare under penalty of perjury nder thc laws of the Statc of Washington that the foregoing L lrue and correct. <br /> ��f �� a�,3 �,��e� �Jw�>,��� <br /> S�gnature of lai a � Date Place signed(city a d sta[e) <br /> Rev.07109 <br /> ��. <br /> Z/Z <br /> ,., „ <br />