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IL if this claim Involves a vehicle acddent/collislon, <br />DnArrf A'unro / LYAcrlr L!a <br />Oxmvi[mwamealn' +Y ync <br />12. Names, addresses and telephone numbers of all person <br />13. Names, addresses and telephonynumbers of all city or <br />your vehicle Information: <br />In or witness to <br />employees <br />knowledge about this Incident: <br />14. Names, addresses and telephone numbers of all Individuals not already Identified In #12 and #13 above who have knowledge <br />rega,ding the ilablllty Issues Involved in this Incident, or knowledge or the Claimant's resulling damages. Please Include a brief <br />desa'Phon as to the nature and ex d of each persons knowledge. Attach aJdil{onal sheets if necessary. <br />15. Oesarit t e cause of the Injury or damages. Explain he extent of property lass or medical, physical or mental Injuries. Attach <br />addltional sheets If necessary. <br />16. Ilas this Incident been reported to law eNorcemen), safety or security Personae ? If so, when and to whom? <br />17. Names, addresses and lolcithone numbers o treating medical providers. Attach copies ooraA medical milorlsand bglings. — <br />Ig. Please attach documents that support the clolnis allegations. <br />ig. 1 claim damages from the City of Everett In the sum of;. SX 17-74-C >'=577ityATEr <br />he <br />manL <br />ho holds a wrItteii <br />atttlorney forim uthelust (1a mantslurred by either by an attorney ahe taimant or on lawadmitted to practice In he State of Washington, or by a�comtapproved gupower <br />dlmr or <br />guardian ad Illem. <br />i declare under penalty of perjury under the laws of the Stale of Washington that the foregoing Is taco and correct. <br />ROV. 07100 <br />