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<br /> 11.If this daim invo;ves a vehide acddenVmilision,pmvide your vchide in(ormation: . - I
<br /> � P/ateNa. Mate Atode! �-Yevr� �
<br /> Dn��is Name � � � � Ori✓c�51/mnsr Mx � VeAk�e 0�4ner(sJ(i(6/hrrvrl hdn dn�rr) � I
<br /> . .... . . . . . . . .-.... _. .._ . I
<br /> OHrrtr'slnsvrartmCd'nvuny . � � � ohoneNo. N�2yNo. �� �� �
<br /> �1 t� mcs,addmsses antl t leyhon/c-num6crs of aU persons invoJlved In�or witn:ss to 1�is inciAent: f �j
<br /> �! �� �� , ,t J .Y �; � > � 7�� (,� .i���)/.(� -ll_r�� �,�/1 ! ���:./C�`�>)l �
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<br /> � 13.Names,addresses a�d IeleDhone numbArs o all Ciry cf EverMt employecs having kn}�w:Sdge abnu(�t lbi,fncident: , ` '
<br /> .� /�1 / r/� i � / �j � ��r ' f� � j� f 3� 1 t. � �il�.'J'�. i1 n/�il' :.1 '- .'� •F ` � 7 !1 ` .
<br /> . � } F p� � L��t � (,!� h ��l'D�%{!
<br /> il`;%,(�./�� � .!'1/i11 .`'1�l .' i!'�:rl��-.r�l')�7 � !1'�'.1:3 /% i��%�A�V�it� 2/'1'ri D/?�il r"5.,1 �.(��l _ J
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<br /> '�';� 14. Names, addresses and telephone num6ers of all individuals not almady idcnlificd In k12 and S13 above�vho have knowledye
<br /> � ' regarding Uie Iiabillry Issucs Involved in this Incidcnt, or knuwledge of�thc Ciatman['s resuitiny damuges. Picase indude a 6iief
<br /> desc�r�l Uon as thc natvr and c cnt of ca�h person's knowledgc. At��h a! i6on I sheets IF nccessa�. J
<br /> �C�,[7 ��/(,t� I`�/�)1'� i i�� i��ll�( �(.�%�)\ i � � t�`Y � �' ''�`��S �� )inl (I�i���J_.r�f;� r.('�_��
<br /> `�1�() ,' . Y�t' ,k )(`!'t�,> t�vYi�'�,�Lv',r_.ii, ✓L�11J1!_/_:i�._�_�'I c, 77—
<br /> ;l ���� ,C�1;'�1,'l�,�'�!�����k�:;�yr� ';�.,, ;�'l r•!�') �1:.!1,f�J1/'i '�L�,L. i r'� �'4-�-_
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<br /> `�� 15. Destri6e lhe tause o`tlie InJury or dama9es. Explaln the extent of properq�loss or medical, physic3i or mental inJuries. Aflach � i
<br /> ��`C adtlitl��al sheets if necessa�ry. r � ' � � ,� I
<br /> +� .�� w��� i ,� . , :°' '�' ° � ( ` � ;� ,!/� - 1 ��'_ � � l� ' �Jl )•,�� �' � . I
<br /> ,. r'��'v,; ) !`ri � .r )•'a,r :i �c � � :� �• .�i t ,:�d�7r�v i ,;�,�;t�i �� �
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<br /> ,� .. !.� � l�/1 <�j +' �' ';i�. �% j ��'1` ,l .iJ tl�S 't . �>, �. •, ��'
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<br /> �1G.��as Oi)s/nc�d�nt�r�en� portcd t�yl�w`�}foicemenf safety oF ecudty personnel7 1f so when ari�1 to�w�iom? /F
<br /> _ ��_% � ' f ! / � ir � 1��I f /�)i}�a ,;;5r)�.�;�!��1 �'1 � f�'�1� '��' . r�t`..✓`� '? .
<br /> _r_'c7(. �t .. ( � : 111 c� ! . l�,e.:� J i, , ,:, , - l L' t� ;. _ .
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<br /> 17.Names,addre,;es and telephone numbers of treating meAiu�t providers. Attach copla of all medical repods antl bll'Ings. �1l ���i:f--� I
<br /> .� --- ___.__ . ___1:`� ��---- I ----_"" '�
<br /> d8.Plcase attach daumenls tha[support lhe clatm's ailcga on 1:1���� . s! �J✓J ;� d.��rl}�". .�{��1) � � .��_f�t')�yi1�e�.�?.!� I
<br /> � � � � 1� � �i � �(i� � �C/`17 I V i�1�� �
<br /> 19.t dalm damages from lhr.City of Evemtt in thc sum of$�� �.� ,_�( J(��.�t�Z.�,�(4Y i (h] �> �/�1.C�l.�t.�
<br /> 7hls dalm form must he signed by dther Um Qaimant or on belialf of lhe Claimant 6y an attomey-Imfact who holds a�vritten power of
<br /> attomey(oi thc Claimant,or 6y an attomey at law admitted to pmdice In lhc Statc of Washington,or by a tourt•approved guardian or
<br /> guardian ad Iltem.
<br /> J dedare under penalty of perjury.under�c laws of the SWM of Washington thal the foregoing is true and cotted.
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<br /> Signatu�e�of Claimant Date Place signed(city and sWte)
<br /> Rev.07108,' �• �' �1 !
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