Laserfiche WebLink
i <br /> i <br /> I <br /> 11.If lhis daim Invoh�,s a vch�de a¢i:lenV�olli;ion,pmviAe your vehlde inlormalion:_._____ _ I <br /> — -- <br /> \�l Mate No. Plukc ldoAe! 1'car <br /> __�'l_—____- .—. _. '_ , _--____ __..__..__� <br /> On�rr's Namm ��✓cr's Umasc ho. t'ehldr ONna(sf(r/AN/cn'nt/lom divcrf <br /> O�mci>/irsmaiKrCarr�vny — __._— , PMnc/!a- � - '— /bl;,yNu. _--_.— <br /> 1 L Naines,addrascs and telephone numbers of all persons involvcd In nr witnets to lhis incident: <br /> _.�� �vNnJ _+ �M��un�n� �{f�: ��� �7�� !�_fs_k Z -- <br /> — — - -- Pt ���?--�7�—�'�-C' 26 z-o <br /> 13. Names,addresses and telephane numbcrs ol atl City of EvcreR ernployecs having Anowledgc abou[this IndAent: <br /> --- - - -- _ _ . . -- - - -- � <br /> i <br /> -- ------ �--_ ._. - - ---� _ i <br /> 14. �2ames, addresses and Ieiephone num6crs of ali indlvidual.�: not aliwdy IJenlificd in Jtl).and lt13 abovc who havc knowledgc I <br /> iegaiAing the IlabiLty issues InvnlveA in Ihis Inddent, or knowled9c nf Wc ClaimanCs icsullin9 damaqcs. Plcase Indudc a bneF � <br /> desniption as to the wture and calcnl of cacli�xrso�i s kuotvledge. Allach additional sheels If neceskiry. <br /> �--- ------- ----- � - --- � <br /> 15. Describe Ihe cauva of t:+e injury or damages. Explaln the extent ot pruperty loss or medi�l, physical o� menlal in)uries. Attach <br /> nddihonal sheets If necciary. <br /> Dl.c�__�s��r���^'ns--�c�o�.Q�/� _fl�� �.�J or s�cv_ w�K <br /> or.1--I�uwGu-s•f a�9h��� o,✓ s/tY�,=,a�Bh:2 _h__f``_2oi3 �!7>�--�`07' � <br /> _�.-�or�L—B�z'✓i_-- o!-"F��+nt»t L/i�Fe,�r._-r, o«_�_ l3�u�eoru�+ �1WiT��-s <br /> ._/')WO LLfJ�,•�Cr-.POO,J��y,��V•e�fS /IS ta7lELl. �I.S_--�u�-.-_.�/%G�fTz.� �"�O I <br /> �— <br /> C3 �ft ' A�t. fi'r7� t9y�'-G. .Oh'!;/!� /�Y t,v/1r%;�C-__�'c?�9C_ �,� Fi� c,c.,�_ <br /> Y s��i..i�ou. 73�i�ir�r.��r, <br /> iG.I las thls Inc yde�'n�t lxen mported lo law en(oicemenl,sa cty or securlty{ursonnel? If;o,when anA tn whom? <br /> —-- --`f------- . '..---- — -- ---� - . <br /> 17. Names, addresses and telephone numbeis o(treaUng medical proviAeis. Altach cepies ut all meAl;al iepoits and blllin95. <br /> .. --- � --(� -- - -- - --- <br /> 7 d.Plzase attach documenLs tliat:upport lhr clNm;s allegatlons. <br /> 19. I daim damages from Ihe Ciry ol LvCRtt In the sum of$___�(�U __.__ . <br /> lhls dalm lorm must be s19neG by Nthcr U�c Clalmant or on 6chalf of Uic Galmant by an attomey-in-fact�vho holds a wdttcn powcr of <br /> allorncy for thc Claiman[,or by an attorney at Wri aJmllted[o praCKc in thc Stafi o1 lVashington,or Uy a cnurt-approved guardlan or <br /> guardian ad Iilem. <br /> 1 declare under pcnalty of pehury under lhe laws of the State ol Washington[hat the foregoing Is W e and cortect. <br /> �,.?i�, • - _� S– i��•�+�3 CGe/6� Lc,�3. f�����. (.�J/i, . <br /> Signature of Cla' ian � � Datc Place signed (city and s4�te) <br /> Hev.orroe <br /> � <br /> ���� i <br /> . .... <br />