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<br /> 11.If lhis clalm Involvc,a vAhldc acddcnV�'��sion,proviCc yaur vch{dr Informatlon:__�_,,,-. - - - �- .�.-- .
<br /> f/a.'eh:? PbXc . .'MJCc9 - "Yea� .
<br /> 0;6rhNa'mc ' � . . . . O�h�esLi�cnsrNo. YPIi.'de0s�rei(sj(r(0��9c•mfficmd�i�r:) � � �
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<br /> O�.�afr's/n5ur.vrccCortnmy—'---_'`J-` VhuneNo. � �!.�yAy. . - . .._. _ --
<br /> 12.Wamc.,addresses and tclephonc numhers of all persons InvoWed fi or witnrss o this Inddent:
<br /> .�c - >�'__-� c�19iL� . �' -�� �^T!'.c�;(:,1 G���-���l�v� �),3-{��C,.f.'�cn��� �1;�:L:YL�n�;3� o��r,7,
<br /> .L)i_�5\.�:�s�Y\:1n�s�-i9l_c�:�..{'_�."�'_��_��,3�� 1 � c ' >-;:��Ci�GL`z7�lr�(�:�,.��-�xG'41�- 1�5�
<br /> Sr,t��4�.a�t�-i`•'_-1t'�..:�`1Li-1L:5.L_f'�,:"Y .�c'_,C\��:Zc�(. -k01-9i�3'�5, . --- _
<br /> 13.Names,aCdresxs and te:ephore nu�r.bers ot all Gty of Gvcrctt emptoyecs having knaw�edge aboal lhi;f.icident: y
<br /> `�a� _r� ..�Q1t���r.��7--�.\'-� .,����..�'- �Jllx�fll\'��i�'���'J�'�' � �r ,��] .�.,VY(>I
<br /> 1��� �� �_l._:...{��i_C-1-sa�,i' r:�����'�rC�,_�'' ���-.��_`�_��—_
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<br /> t4. Names, addres;es and tMephonc numbers u(all Intliv�Juals not dready identlficd In R`II ard %13 a6avc who havc Y.nowted9e �
<br /> icgardmg Ihc I�abi6ty i,sucs Inwlvcd In this InciOen[, or Wiowledge ot the Gaimanl's resu;;in9 dumaqes. Dicasc inctudc a hrict
<br /> deSalp;lOn as to ttie nature antl evtcnt nf ea�h person's Anowledge. Altach add'�tionai sheefs if nccessary.
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<br /> ,—rr...._. . . . ... __. . . . . . . . .
<br /> 15. Desctlbe ILe ause ol lhe Injury ar damage:. ��plaln the e.tent o'n�operty loss or mCdicel,physlral or mental in7udes. Attach �
<br /> add4ionai sheels d netessary. �� i
<br /> .1SLfl�' �— T��.Q�—L"1_�5��:���" r�� . �Mlg7�,,��-�'n���-___��1..:-�-�1' • i�l�l._'1\L, � '�
<br /> � C��1t'.. f7�lY1Y�l__311 .� ��,c,_ • ��J:- ����� r �� ���].X__Y�_-_.— \ j I
<br /> :�'�-1� C..i � �i c;� t �.'C..� °s �_�.Q�_z„G�rt.l�;�, lnc_`!. t�>��r• <1z.5-f,�.Je.cl �, �
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<br /> \r ,__rr L'����� t� ���L�i�,1�,i+1� �i .Su�'1G.�'..�}-�1 S��C..f� r� �`��
<br /> _h��\ �T��aS'J�1'_�.L1't.C_'_L��`'�\'\�.S_�i_RC�-'�-��`.�--.�41'K' \ l,, ��, �.�` \.��t C`rl:�T'.
<br /> 16.HaY4his in=ident becn rcpertcd to Iaw enforcemrnt,s�lcty or securiry personneV I�s ,when anA lo wh�mt�1�1U2-�',�y>l n l.l'."�'p
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<br /> 17.Names,addre.;es and tdephone numhers ol treating med�cal provlders. Attam rnples of all medical reports and billings. ;
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<br /> IN.f'Icase allach documents Ihal suppnrt the dilm's allcgaUons. �
<br /> 79.I daim dan s�mm Il�c Gty of Evcmll In thc sum of�,� C��<��' l',� F_,\��(T\1'(\/�. I
<br /> 1 hls claim form muri he signed t�y dlhcr the Ciaiman!or on behalf of lhe Claimant by.n atlrnney�imlact whn hnlAs a wGlten pov+er o1 �
<br /> attomey lur the Qalmant,or by an attorncy at I,nv admittcd to pr�dtcc in thc Statc of elaslun9ton,or by a rourt�appmved guatAian o* .
<br /> guardlan ad iftem .
<br /> I declare under penalty o!per�ury unAer the laws of lhe State of 1Vashington tha[ttm fore9o�ny is I�ue and carrect. .
<br /> i>c � �����e4L ..T, G~�� ._ �`� !�_�;.C����C���G2��ll�4��"i\
<br /> Sign fu of Qfa�ant/� � � � Oa[c Place sign d(city and s[ate) �
<br /> Ro�.o,m��,�'.�-- l�C�v��'�"'� ��-g� �� �:� e'(e1��-����a.���c:� t`�'�r>Y'�
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