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*, 200

Re: Our Client(s):*
Date of Accident:*
Time of Accident:*
Location:*

Dear *:

Our file indicates that you might have witnessed an automobile accident which occurred on the date, time and location indicated above.

It would be greatly appreciated if you would complete the following information and return it to us in the enclosed stamped, self-addressed envelope as soon as possible.

1. State Your Name:
________________________________________________

2. Residence address:
______________________________________________

3. Telephone No.: Home:__________________
Work:____________________

4. Specifically, where were you located at the time of the collision?
_____________________________________________________________________ _

5. If you were in a vehicle, please state the following:

(a) Street on which you were
traveling:____________________________ _
(b) Direction you were
traveling:__________________________________

(c) Which lane were you on prior to
collision?_______________________

(d) Were you driving? If not, where were you seated?
____________________________________________________________

(e) How many lanes of travel in your
direction?____________________

*[Witness Name]
Page Two
*[Date]

6. Please describe the collision as accurately as you recall, i.e., state, if possible, the following:

(a) Color, make and year of each vehicle:
____________________________________________________________

(b) Description of driver, i.e., age, sex, etc.:
____________________________________________________________

(c) Number of passengers in each vehicle:
____________________________________________________________

(d) Street on which each vehicle was traveling:
____________________________________________________________

(e) Direction of each vehicle:
____________________________________________________________

(f) Lane in which each vehicle was traveling:
____________________________________________________________

(g) Type of traffic signal, if any, controlling the accident site:
____________________________________________________________

(h) At the specific moment of impact, were any signals controlling East/West or North/South traffic? If so, state the color or type of signal for each direction:

____________________________________________________________________

7. State the position of each vehicle involved in the collision immediately prior to the impact:

____________________________________________________________________

8. Did any driver make a sudden movement, regarding lane change, braking, turning, before the impact?

____________________________________________________________________

[Witness Name]
Page Three
[Date]

9. Did you hear any horns or screeching of tires? If so, state when and from which vehicle the sound came from:

____________________________________________________________________

10. Did you discuss the accident with any person involved after the impact? If so, to whom and what did you say?

____________________________________________________________________

11. Who do you think was at fault for this accident, and why?

____________________________________________________________________

____________________________________________________________________

12. Please indicate weather condition at the time of the accident:

____________________________________________________________________

13. Please state anything else you feel might be important for an understanding of the facts of this case:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

I, *[Witness Name] declare the foregoing to be true and correct under penalty of perjury and that this declaration was executed on _______________________, 20______, at _______________________________, [state].

___________________________ *[Witness Signature]

On behalf of our client and our office, we would like to thank you for your cooperation in completing this form.

Sincerely yours,

___________________________ * Attorney At Law

Enclosure

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Relevant Laws We STRONGLY SUGGEST Checking Out
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