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<br /> 7 i.iF tfiis�c�alm IBvoNes a vehlde acddenU�ailision,providc your vr.hiQc infortnation:���� _ _ -
<br /> � � Vlafe No. Makc M�9 � �1'caP�
<br /> On`ri'sName � ��� � � M'veF'siimnscA'o. Yn4Me0wnws)�fdl/cmnNromdi�xr)
<br /> Ow�er's/nsmaa'r Ca.�any - Pk�v�c�Yo. . . - Poiry hb: � .. . .. .`. . — .
<br /> 12.Names,addresses and telephonc rumbcrs of all peaons Involved In or wltness to Ihis Incident:
<br /> \� \, �� . . . .. .. -- . . ,
<br /> t3.Names,addrcsv_s and telephone numbers of all Ciry of Evemlt employees having knowledge about this fn:lden,: I
<br /> S\•�r� s �.�?��r– as� -Y.9 ��� -�o c��('.Q ,�� � �._,...—. �
<br /> . � 2 U1�..�, Li.��..,-�t�>��, t-,�,,- r,�e4 �.. b�;,,-\ . 0:3 �x 7 a? .
<br /> 15. Names, addresses and telephonc numbers of all Individuals not already identificd In k12 anJ t�13 ahovc who havc knowledgc
<br /> regardiny Uie I!ab!I�ty iswcs in�iolred In lhls Incidcnt, or kno�viedge of the C�aimant's resultlng Aamages. Plcase indude a bricf
<br /> descr�ptlon as to tfie naNre and enten[of each person's know�edge. AtUth addition I sheetz if necessary. ( '
<br /> C'��a.q�� Q�v,�ch:, -• Z(rc1�c. ? - ��.�.�y- ��t�.S��u`<7��o.,IlZa„�o\c4�"��jQ.9,m�
<br /> — . _i�.-e.. �� :------ F _. �i;4. �� l W 7�..� �x�,�_�.,,� .
<br /> I5. �escribe the cause o!the In}ury ar damages. Ezplain the eztent of property loss or medical, physical or menWl injudes. Attawh
<br /> additlonal sheets if necessary.
<br /> 'T �- ,�, \''Af2L,vhQrJ� `1.C7?� ��.A`n�R����, 1�+�0.� �X).�:)?lL.-.��c�CC,L ' ,\aQ .
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<br /> i6.I{as this In:ident 6cen reportcd to law er.forcement,safcty or scadty personn�JT If so,�vhen and to whom?
<br /> 17.Names,addres.�es and telcphone numbers ot treating me�ical provlders. Att�cb copies of ali mediral repoAs and billings. .
<br /> lU.Please attach documents that support the eliim's allegations. \0 ��K!��� �
<br /> 1§.1 elaim damac�es from U�e Ury of Everett in lhe swn o(S� �CS.`_QdLyY�`^-�' ��
<br /> 7hls dalm fo�m�r,c,t be sl9ncd by ci'�her thc Gaimant oc un bchalf of Ute Clatmant by an attorncy-ImfaR who holds a vrtittcn power of
<br /> aUomey(or thc Galmant,or by an attomcyat law admittcd to practire in lhc State of VJashingtpn,or by a murt-approved guaMlan or
<br /> guardian ad litem.
<br /> 1 dedare under penalty af paJury under Ihe lae+s of Me SW[e ef Washingmn that the foregoing Is hue and correct.
<br /> Si�,.,l�s9yst � ��,�n. \4 `'� �� � '���- v:�� �
<br /> �e oF Clalmant � � Dat � Placa signed city and sWte)
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