HomeMy WebLinkAbout25-80870 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
SASE 25-80870 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
cowsloN 12 - 19 - 2025 1650 17 . N E IN� S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
KIRKLAND AVE NE
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e NE 12TH ST
1 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:2065560935 30
6� LAST NAME GHAFAR FIRSTNAME USMAN MIDDLE 1 2 31
INITIAL
STREET ❑ 20227 4TH PL S CITY DES MOINES ST WA 21p, 98198 z=
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
,/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10 2❑ I P1 ATNES# CFG0449 sTAr WAv N# JTDKN3DU6D0352501
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. RLR 1 7 33
12❑ vIN#' UIN#
:: FROM TO
VEH.YEAR 2013 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 5 34
13 TOYT PRIUS DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO USMAN GHAFAR 202274THPL S DES MOINES WA 98198 D:2065560935 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO PROGRESSIVE 971655729 3 4
IN EFFECT &POLICY# 9TOP
VEwcLe 1 5 36
Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ LEGALLY STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN ✓ PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES,/ NO D:9074190761
16 a
LAST NAME WILLARD FIRST NAME DEZAREE MIDDLE L
INITIAL
17 STREET IST AVE SW CITY' SEATTLE ST WA ZIP 98146 4❑ 37
NEW ADOREs�' 10602 1
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 DRIVE # STATE SEX F M .C.B. 07 09 _ 1982 39
20 ON DUTY STATUS 3 AIRBAG RESTR EJECT H SET 2 INJURY6 [NATURE OF INJURIES
CLASS COMPLAINT OF LEFT LEG PAIN ❑ 40
❑21❑ TArE 41
LICENSE VIN# 1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4 0 1 DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
vE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N J
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# T AGENCY
26
JAKE GALL 12617 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG60916
COLLISION REPORT III III III III III 111
1591972 CASE# 25-80870
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
PM USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIRST MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JAKE GALL 12-19-25 06:43 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
M.BRAUN 2194 12/19/2025 10:23:47 PM
BADGE OR ID# ` 12617 OR]# WA0171300 TIME POLICE DISPATCHED 4:51 PM TIME POLICE ARRIVED]4:59 PM
PART I PAGE IT]OF 4�
REPORT NO. EG60916 CASE# 25-80870 OF COLLISION
12/19/25 16:50
OF CbLLI510N
NARRATIVE
*This incident was captured on my body worn video camera. This report is a summary of events that
occurred and is not an exact sequencing of events. Statements have been paraphrased and
summarized. *
The following occurred within the City of Renton, King County WA and was recorded on my body
worn camera.
Unit 1 was stopped at a stop sign at the 4-way intersection of NE 12th ST and Kirkland Ave NE. Unit
1 was facing North bound, attempting to navigate a left hand turn to go Westbound onto NE 12th ST.
Unit 2 (female pedestrian) was attempting to cross the marked crosswalk on NE 12th ST. She was
walking from North to South. Unit 2 was wearing a red hooded sweatshirt and black leggings.
I spoke with Unit 2 in the back of the ambulance. She mentioned that she was using the designated
crosswalk, when Driver 1 entered the intersection and hit her. Driver 1 stayed on scene after the
collision. Unit 2 was mainly complaining of left leg pain. Renton fire cut the pants to expose the injury,
but I did not observe any obvious external injuries to the left leg. Unit 2 was transported to Valley
Medical Center.
I spoke with Driver 1 and brought him back to the intersection so there was no miscommunication as
there was a slight language barrier. Driver 1 said he had stopped at the stop sign and made his
lefthand turn onto NE 12th ST. He simply did not see unit 2 and hit her "at low speeds".
There was no sign of impairment when speaking with Driver 1. 1 collected all the necessary
information.
I did not observe any damage to Unit 1.
I completed infraction #5A0801754 RCW: 46.61.235 for Driver 1.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by J. Gall/12617
12/19/25 at 1806 hours, Renton, Washington
PAGE 3 OF 4
REPORT NO. EG60916 CASE# ' 25-80870 DATE AND TIME 12/19/25 16:50
OF COLLISION
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PAGE 4 OF 4