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i <br /> � <br /> � <br /> II.If this daim tmvNes a veht�le awideMJtoliklon,pmuide yaurvehlde informatlon: <br /> Atrte nta Pkke Afad�M Ycv� <br /> OVAs'sNsme �— Dh'�[A�aseNn. ---- VM.�deOwne�'s)p/d7/e�CntNwnahYer) <br /> Ownarslnstua�CmKuny MaxlNv. qy,cyNa '— — <br /> t2.Names,addresses and te!ephone numbers afall persons Invohred In or witness to thls inddentr I <br /> T��o�.��s t�c��Lu� T_�me �s c.l�a.� 4as- a��o <br /> 13,Names,addresses and lekphone numbers of all City of Everett employees having knowledge aboutthls incident: <br /> UtY1 JLO 11��'1 -.- <br /> 14. Names, addreses and telephone numbers at all individuals nat already Identlfled in ff12 and X13 ahove who have knowledge <br /> regarding the Ilabllry Ittues Im�oNed In this Incident, or knavledpe of the oaimant's resutting damages. Please Include a 6rief <br /> desalptlan as to the nature and exteM of each Dersan's knowledg>. Attach addltlonal sheets IF necrsary. <br /> u'��--- -- — <br /> 15. Desaibe the �use of the inJury or damages, 6q�lain the extent of propeity loss or mediol, physical or meMal InJuries. Aqaoh <br /> addRlonal sheets if r.ecessary. <br /> _.j�r�d�ti �Cb C� �oC _� camP ou.E^ OQ�or' <br /> g.7ti'���.(Yl�.���" �tL• ' C9.1�-t.�s��t-�— <br /> �U.Y' <br /> Jat,C�- SP�7� r _ {'larn� <br /> 16.Mas this incident been reported to law enforoement,safety or securlty personnel7 If so,when and ta whom7 <br /> �(g����u P_-��C� ��-`.. �(o�M_t,� s�Q �,� I�ID.��-�-1� <br /> 17.Names,add and tel Dhone nu ers of trea ing medical providers. Attach mpies of all mediwl reports and blllings. <br /> ----N� — ------------ --- <br /> � <br /> t8.P�ease attach dotuments tha[support the dalm's allcgatlons. <br /> 19.I ckim damages from lhe Gty oFEverett In Lhc sum of$ �����Q_ __, <br /> lhla dalm farm must be slgned tr�enher the Glaima�t or an behalf oF the Claimant hy an attorney-in{act who hokis e written power o( <br /> attorney Por the Clalmant,or by an atborney ai law arimftted to pra�ilce in the Statc oF Washington,ar Fry a court-approved guardian or <br /> guardlan ad Iltem. <br /> I Ooclare under penaky of peryury untler Ltie laws oFthe:Bate of WashingNn that the faregoing ts true and cormct, <br /> �(�_� �(A {�_ 8�30 �013 �i1��� wC� <br /> Slgnature of Claimant Oabe Plaoe olgned dty and sla�)� <br /> R.v.mraa -- _-- — <br /> �� <br />