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- i <br /> � , � <br /> XS.IfffiIsdalminvoMesavrhkJe�a[dden[foollision,pravideygurvchldcinformatlon:. •.�- � �� _ -._._..._ . ..__._- . .__._ �� � <br /> ' � P:a7eNa. , Nakc � MoAcJ � - -'.Ye3'r� .. <br /> .. . . . . --- - : <br /> -�omrr'sNanie . ._ . .. . '-. .'... . eGivei}ucenseNo.. .. . VNrid'e0ivner(s)'(i!'d'flrmiNromAnver) <br /> .. . _ „__._ .. .. . _ .. ... . .. . .. ._. . . ._ .. ...........,.,.., _ . <br /> Owne/slnSmanreCump3ny., .. . . .�, PhoneNo: � PoSryNo:, . .. . .---._._ . <br /> 12.Names,addresscs and tclFphone num6crs of aIl�crsons Involved In or wimess to[his fncident � <br /> 1-FK�,n1� '1�,A�!��2. <br /> � DFr�u`� �1�N�.r�z _ . � . , <br /> , A l - 1�ANl.�i2.. _ ��u'1�� I�A�a�le...�R. __ _.._ . . <br /> 13.Names,�ddresses an9 telephono numbCrs of all City Cf G6erett emplo ees having kno�vledge ahnut lhis Incidenti _ ' I <br /> �',.(?���Rt�1p�_ CCI,A��S AD'7VST� , ..____ <br /> ,.�Bg.��J--....���u�.�..�unR���- _ ,_.�. <br /> 14. Names, addrcsses and telephone numbers of alI individuals no[a�rwSy idenli6ed In fk12 and k13 above who have knoivledge <br /> regarding the liability Issues Involved in tttls Incident, or know�edge oF�th¢ Clainant's resultlng damages. PleOse inetude a bricf � <br /> descriptloh as to the nature and exMnt o(each person3 knowiedge. AUacli addilionai sheets If necezsary. <br /> :-`"v.......,. _ . _ . _ ,.._. . _ . .. .. .. . . . � �- <br /> I5:Describe the cause oE the faJury or damayu. Explain the extent of p;operty loss or medical, physiral or mental Injuries. qUach � <br /> additional sheets if necessary. � � . <br /> SL��1� u�a-�.a. �.F2�M__ 1���E Al.��� F w41�En..-r�1�_��u��, <br /> Cl : . . ..,w 0 N . �1�Ot_Ll . p�� -'(3fKi�r�eN'r.�lJ tr-C uxz3-et? 'la.� c' <br /> . ._. X!2 � T � �ecQ k2d. P�pm bY Ig ' �b�caom �Ou�y� � <br /> --�•-.-��-��t (� . . . _ . o---1 <br /> ������ ���b� �b�S�'�ri ma S. '14��x�%c�.W.L-L�....�31!a�.C�.soow�� �r.�n. 44��� _,- <br /> ��...��*^T��"j��-�L...9_�_511�_�L—'�_7.�1HEQ.S,'AROe�S SX7n�c�i�.•12�V111tey}. . <br /> 16.ilas lhis incidcnt been reporl�d to law cnformmr.nt,safery ar sdurity personr,ef7 �t sa,whr�i and to whom7��r ��� �I <br /> .�_.L� �o-Ni�p <br /> . ...-. <br /> 17.t7ames,addresses and telepfione numbers of UeaUng medlral providers. Attach copks of�II metlical reports and billings> <br /> �, <br /> ... �� . . ... . . . . "�Y.`NT`. . . . . �'�r• .. <br /> . �� .+r� " . .��..-�--�� �---� ' ' I <br /> Y0.Please attach documenLs thai support the dalm's allegatlons. � <br /> UNKNo�N !�-Z' <br /> I9.t clalm Qamages Tmm thc City of Evcrclt in lhc sum oF$: .._ _ _ • TH15 'Y'�M.� , <br /> 7his clalm form must hesigned by cilhcr the 6laimaut or an behalf of Uie Clalmant by an al[o:ney-Indad who holds a wiitten pavcr of <br /> attomey fcr the ClalmanC,or by an attomey at W�v admittcd to practice in the SWh of Washington,or by a court-appmved 9m�dian or <br /> guardian ad Iltem. <br /> I dcclare undcr penairy of perjury under thc laws of the SWte oF Nlashlnybn that thc toregoing is lme and mhect <br /> ' '.�: '�C'Co.�,� 9- 1 - 13 ��,�d; ��- <br /> Signature of Claim.�nt � Date Place sig�ed(city and sWte)� <br /> Rev.D7109 <br /> � <br /> �l I <br /> a�2- <br />