3._ATTACHMENT_3_SF_94_Statement_of_Witness.pdf

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RFP HSFLGL-l7-R-00001 Dorm Management Services FLETC, Glynco Georgia

Attachment 3

STATEMENT OF WITNESS

(Attach additional sheets if necessary)

1. DID YOU SEE THE

ACCIDENT?

2. WHEN DID THE ACCIDENT HAPPEN? FORM APPROVED

O.M.B. NUMBER

3090-0118

a. TIME Da.111. 1 b. DATE op.Ill.

3. WHERE DID THE ACCIDENT HAPPEN? (Give street locat1011 and ell;)

4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED

5. WHERE WERE YOU WHEN THE ACCIDENT OCCURRED?

6. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?

7. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY

8. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY 9. IF TRAFFIC CASE, GIVE

APPROXIMATE SPEED OF:

a. GOVERNMENT VEHICLE Miles per Hr.

b. OTHER VEHICLE Miles perHr.

10. GIVE THE NAMES AND ADDRESSES OF ANY OTHER WITNESSES TO THE ACCIDENT (lfk11ow11)

a. NAMES b. ADDRESSES (h1c/11de ZIP Code)

11. HOME ADDRESS (!11c/11de ZIP Code) 12. WITNESS (Print Name) a. HOME TELEPHONE NO.

WITNESS

COM- Sign here

b. TODAY'S DATE

PLETING THIS FORM 13. BUSINESS ADDRESS (J11c/11de ZIPCode) TELEPHONE NO.

14. INDICATE ON THE DIAGRAM BELOW WHAT HAPPENED:

l, Number Federal vehicle at I-other vehicle at 2-additlonal vehlc:le aa 3, and ahow direction ,or travel by arrow (Example: --4 CT:)CD )

2, Ute aolld line to 1how path before atcident - CD Broken line after accident -------D::)

3. Show pedutrian by Q

4. Show railroad by I I I I I I I I I I I I I I I I I

5. Give riamet or numben or 1treet1 or hi1hway1 6, Indicate north by arrow In thit circle

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RFP HSFLGL-17-R-00001

Lodging Management Services FLETC, Glynco Georgia

NSN7540-00-634-4045

94-105

Part 9, Attachment 3

STANDARD FORM 94 (REV. 2-83)

Prescribed by GSA, FPMR 101-39.8