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<br /> 11.If this claim involves a vehicle accident/collision,provide your vehicle information:
<br /> Plate No. Make Model Year
<br /> Driver's Name Driverst/cense No. Vehicle Owner(s)("different from driver}
<br /> pOwner's Insurance Company Phone No. pal/cy No. '
<br /> 12.Names,addresses and telephone numbers of all persons involved in or witness to this Incident: +,
<br /> t r�,tl ail -- /�1� r �'ce_ - a de phP ii+ ,S Ldl ket
<br /> C*00,14t 1 t 6 4-6 ra
<br /> at /�,/ 3in (9181 ict i dg ,tthw J Mt. &h` - ��,_=� r bet..e
<br /> 13. Names,addresses and telephone numbers of all City of Everett employees having knowie tqe a out this llf►cident t/'O' t) Vale< 1
<br /> (7) Cwiter Rae, Weiks ft Saar gtzs�'-z s" - rv---,40 1
<br /> km 6,erz-i,is 1 i +airtei cia,m$ rl/i 1-4o.-621.-z olz
<br /> 14. Names, addresses and telephone numbers of all individuals not already identified in #12 and #13 above who have knowledge
<br /> regarding the liability Issues involved in this incident, or knowledge of the Claimant's resulting damages. Please Include a brief
<br /> description as to the nature and extent of each person's knowledge. Attach additional sheets if necessary.
<br /> Ple!PC..05 130 di'; Odkei,Z ?. eit.-G)r PrOPeX 6 PeAltod-o4‘&9,2sai--,wi-,seevati-whe
<br /> 15. Describe the cause of the injury or damages. Explain the extent of property loss or medical, hyslcal,9r mental Injuries. Attach
<br /> dppitio�nal sheets if necessa)ry�
<br /> C �,J l,/OTAui .A,-.
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<br /> 249vt ) J Gt 1 p- 1'Il
<br /> 6. 141
<br /> w • ve,,2,-56,041,<_.
<br /> /.2, 1rtuir-
<br /> 0_ _ AtJr- 4- I*n'it t
<br /> 4 e fi-i k .t 4..tr-eJt etd, l r ( --2 , f G�r� l -r .
<br /> 16.Has this,i cident been reported to few enforcement,sil'ety or security personnel? If so,when and to wQm? `
<br /> blti-e-ui--turtet-)w-eff-t4 ca-- *Ler ti-4/ *1)=-- etz&ile.hr-,f•rtfie--e,
<br /> Airkeards)and elephone num of treating medical roviders)ttach cbp of all medical reports an4I billings.
<br /> , ' ,.. rr4-: iJ Wit_ II_IMj..' 1._,_> .
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<br /> 18.P ease atk•ch . n s o e c axm al e a ons. /� _ ,
<br /> zi Oa -j " rPii • f '
<br /> 19.I claim damages from the City of Everett in the sui$ tl
<br /> pp.,,y� �j On f pit
<br /> This claim form must be signed by either the i n'idnt``b d75e�ta1�`of the falm'ajbb an attorney-in-faro holds a written power of
<br /> attorney for the Claimant,or by an attorney at law admitted to practice in the State cif Washington,or by a court-approved guardian or
<br /> guardian ad!item.
<br /> I declare under malty of perjury under the laws of the State of Washington that the libregoing is true and correct.
<br /> i{, -�. �( / v --�, ?PPO/
<br /> Signs ure of Claimant 5 t Date Place signed(cityand state)
<br /> Rev.07/09
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