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f 1.If th';dalm ineaNes a vehide aaldenVro111slon,provlde your vehlcle Informatiar.: <br /> Pluh No. AAke hlodel Y�vr <br /> - O�Hrr's Name CYAe/s[Imnse A'a Veh/Ae nwne�(s)(i(dd7aenf/�um dnYa) <br /> Oann'r/nwraMeConwany OhnneNa. PaLkyNo. ^ . <br /> 1 <br /> 12.Names,addresses and lelephone num6ers of all persons Involved In or wEness W thls Indden[: <br /> 13.Names;addressc:and tclephonc numhers of all Cily of Evcrett mnployces haviny knowledge abou[this Inddent: � <br /> 14. Names, addres:es and Cclephonc numbers o(all IndlvldunL^not a!ready Identllled In #12 and N33 abovc whn ''�ve knowledge <br /> regarding the I!abllity Issues Involved In thls Incldent, or knowled9e o.' fhe GatmanPs resu;tlng Aamagrs. Plea��- ���-1ude a 6de(- <br /> descdpUon as to Ihe nature and extent af each person's knowledye, Atlad�addlUonaf sheels If necessary. <br /> I5. DesMhe lhe cause of lhe InJury ar damagrs. Explaln tlie eztenCaf propeity loss or medlnl,phyalcal or mental Injudes. P.ttach � �� <br /> addlUonal shects If necessary. . <br /> �i'K��yvi.evt-�' ��� `�ac:kQ�� uID SQu�c�e�a ��IrM <br /> _Z-F FYi � .r �?�i�n�S �4 0o d_e.�l�' pA-^Ss1.m` ca••'�. �T ei a�- 1 v��:.T,-p o-�- <br /> '71 r�'vJtG_�y 'f'n S {7nn_�' �.UG-��—W�-�� �Ya 17 �YYZO � <br /> tJ <br /> �o�EE Yr�e�C.s�E �wko--�- l�ff,r.a—QQju��rntio� - • -- <br /> I6.Has MIs IndQent becn repoKed to law enforcement,safery ar seadty personnel7 If so,When and to whom? <br /> 17.Names,addrcsses and lelephone numbers of IreaUng medlral prvvlders. Attach wples ot ali me0lcal mpods and blllings. <br /> f0.Please attach documenls that support Ihe clalm'.s alle9atlons. � � V <br /> 19,I dalm dama9es from the Qty of Eve:dt In the sum o(s._ — <br /> 7hls daim form must bc 9gned by clther the CWlmant or on behatf of the Clalmant hy an attomcy-Indad who holds a wAttm power of <br /> attomey for the dalman[,or by an attarney a[law admltted to pracllce In the State of Washin9ton, or by a murt•aOPro'�ed guardlan or <br /> guanllan ad II[em. � � <br /> I dedare undcr penally of p: ury under thc laws of the State of Washington that the foregdng Is true and conect. <br /> �� . ol-l'� ' l � E ✓���4�Il�- <br /> Sig��cure of d mant Date Place slgned(city and state) <br /> Rov.07/09 <br /> � , �� <br /> �.�_ <br />