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<br /> :L : r,�r Cii'.+ G= _;�cnETT^ � �:iiY USE ONLY
<br /> ��tath:*.ents Distribution� to: .
<br /> - Police Report Claim for Damages rorm Scott h'etzei
<br /> Collision R=port _ t1 J7�G��-��7 Risk Manager
<br /> i Other _ Dept. Code 0 �
<br /> Dept Head's Name
<br /> Dept Head's PH
<br /> i • '- rl 1 f L�
<br /> � Please take notice, that ' L• h'D � /� � � . � ������ _7� , �Iho resid=s •
<br /> at /.-�[• � y L V� �� ' � � � , telephone I „7.�,'; _ c/�y".�� ,
<br /> work phone Il .�,—� _ , ; . l. and ho for six months prior to the occur:rence
<br /> resided at �. • -. i ��•��� " �) ��f">�,klaims damages of and from the �
<br /> � City o` Everett in the sum df $ � an sing out of the following circumstances
<br /> listed below: AZL NICD i CA l �x��iVS C S f�C vc JvG, 7' ��NA !,=��L FZ C�IYI`
<br /> DAY/T?NE OF CCCL�RREtJCE: T� � r�, , 1�"'vs/aT/o(�
<br /> �.�.: . �� �7� Lr � 7 i �8 ,�_ s,�; , 1'�
<br /> LOCATION OF OCCUtiRENCE: E'�lr Si b t .'�f"(�(� .�I p t.l� �C C ���� V Q (� 4'E/�L�-�
<br /> DESCRIPTION: � •
<br /> 1. D�scribe occurrence explaining the nature of the defe ts or acts
<br /> ; of negligence causing damages. S/P�' L✓�� L1� �/1� �r Ry ��� c� Cc+fp;?�:�
<br /> ������ 2. Provide itemized listing of all expenses, injurieS, and losses ' �
<br /> !UL 20 19aZ and attach copies of estimate or bills. S,%; LL � N /�o.= � �rA �
<br /> S�`/�'J� v L e: n Fc �z •Su�2G,�,�).•. .
<br /> �IT_Y C�ERK 3. Provide a list o: witnesses to the occurrence including names,
<br /> addresses, and phone numbers. ���� �Z ��,��
<br /> l�1r� L �Nn � f�c--i�/r� � tx �:�� 7 C�' �Jh u�,�"; l is�' �f/�un �,s7- �Ig,�
<br /> �----
<br /> l lz s�rC v c ('�itKtC ar;. tr % C�ff kfi .�, ; �, ; �-- lil, ' �,.� �
<br /> � , �.
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<br /> z���.,/-f r R V o u r� C- iL1 i�N vV/� �� S i�,P N,= ,> �, � t=! f� �tl�! C S�.
<br /> rJ�a Ni � � E H�-v � N r k c r o r�s r� ���/F n
<br /> I� '�.h �r r� c: r- �io<-.�� . �
<br /> � .
<br />��� .
<br /> (Attach an extra sheet for additional information as needed)
<br />� Additional Information Required for AUT0�40BI�E CLRIMS ONLY
<br />� License Plate No: ' Driver License No. :
<br /> Type Auto:
<br />�� (year) (make) (model)
<br /> DRIVER: OWNER:
<br /> Address: Address: �
<br /> i ,
<br /> I Phone �l: Phone Il:
<br /> PASSENGERS:
<br />� tJame: Name•
<br /> r
<br />� Pddress: Address•
<br />�
<br /> Ot�,�NERS Insurance Co. h Policy No.
<br />' n/ �/ /� r
<br /> I,�?"�f�� (} /"/�i�C�✓�-�^/- , being first duly sworn, depose and say
<br /> ti�at I am the claimant above described; that I have read the above claim, know the
<br /> conCents thereof and belie�•e the same to be true.
<br /> SUBSCRIBFD and S'.IORN to before me this � , / , �
<br /> �O day of �7'(t /, Y , 19i��. � t( �"' /7�,1`G'�✓�c,y-
<br /> �
<br /> � .:i,t:�� I����. ,
<br /> ��OT'�(1RY PU�vTC ih an�,i far the S�:ate r,f ',lashirn,.n��,
<br />
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