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<br /> 11.if this'daim Inwtves a vehlde acdden4�o:lision,provide your rrhiclr.idomiatfon:11� A� � _ . �.- ��..z_„
<br /> .� . � . P/�.Mt Makc _ ..-ModJ .� Y'pii� ..
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<br /> � �On�r%sf�amC � - � 47ia'sLicm.mNo. —y VchideONnerd)�(i�4RFJcrr.'fi�md'nrr,� �
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<br /> O�merS/nsuaKcCwrywny . - PAMeNo. _ . FblityM1r.. .. _. .. ___, .
<br /> 12.Names,aAd�enes and tclyitione nu�i6ers of all persons Invqlved In a wttness to ihis Incidrnt: �
<br /> ��..�5���,�„' "
<br /> 13.Names,Bd'Nes�s and te!ephone nvnbers of afl Cityof Everctl employe s having�Y.npw��de�dgc a t.lhL•incident: �.
<br /> ��'�f; �.'�'a,Y.� �.r� �1�`1 �(9 S�_ '�� �7419.yt.,� ;
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<br /> S�c�.. 'PZ-u.,.,�. Ci�, ' � s. y1_ ,1�.�._ � SP�_ �,—�.. l�. --� 03 —R'7 �.�, .
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<br /> t4. Names, addresses and tclep'�one numtiers oF aH ind�viduals ndt alrrady itlentificd In #12 and A13 ahove who htve kn�vledgc
<br /> regarding lhe liab�ity Issues involecd In thlv Incident, or Y.now4edge of lhe Galmant's rr'ulling damages�. PlcaSe Inticle a brlef
<br /> desvlpllon as Ip the nature xnd c�lcnt of cach person's knowledge. AUach add�tlon I sheets If necessary. 1 /- �
<br /> C T�3�lJ�J.S. U\VOdC.� " �. �K . .E .-�ti:� \�V��\ItiS7/lV4�Au�I�Zf.MOt1'�\�`�1Q7�1��(t�p 1.
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<br /> . , ` C�� e'�'t- '-l W�t� �Xtnw'�;`Cl, .
<br /> I5:Demibe the rzuse nf tlx Injury or dam�ges. Er.plaln the extent of Dropedy Ioss or medlcal, physical or menWl injufies. Altach
<br /> adAitlonal shee[s if nemsary. � .
<br /> �.+� 1���:�,����-�-� c�...��r�...��.-�. s4.,.�� ..�k4,.���
<br /> :. � . u:. �.S . . ..'� =r'° .i/1._'-:ti-Js�i�-,., t� c A�h V'•. F.---\T�_ ;,;>� �� � .
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<br /> _- - � —�- . Wc�ew �Jl�"�, '.c,�,.(---!`!}•y,s�..._��VJM{v1L _��'�,{1r� �.
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<br /> L6.Has thi<inciden[bcen tc0oital to law enforcement,satety ot scadty personnel7 tt so,when and to tvtiomt
<br /> 17.Namcs,aCdresses anu[elephone numbers of Irentlny meiliral pro�Jers. Attach coples o(all med�,cal reports and blNngs�
<br /> �l9 !Icasc altach doamenls that aipport lhc dafin's allcgatbns.�0 C7�X9SW
<br /> .._ ., ..., . ..
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<br /> l9 I tlaim darapes irom the Gty ot fverett in Um sum of�.���,�..1•.cf -
<br /> Thls daim[orm must hesigned by alher Uie fJaimanl or un behal(of th�c Claimant by an aUomcy-Imfru.who hnlAs a wrlten pa•rcr of
<br /> !tomey(octlie�almanC,or by an attnrr,ey a[law admittcA to practlre In tlic Stale of WashingWn,or by a covrt�aDD'��9uaMian ar
<br /> guardl�n ad Iltan. .
<br /> 1 detlare umicr penally of pehury under the I.ws of the SWte of Washinutnn tiwt the foregWng Is true xnJ carecL
<br /> Si�.,c.�—�4-R :('. `M 1!�(��,�� c� �a �Z._�_v���3- �� ..
<br /> �e of Claimant '� Dat pldce slgned tlty and sWtc)
<br /> Rar.07101 �
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