LOCAL REPORT NUMBER * REPORTING AGENCY NAME * MEDINA TWP. POLICE 2 DECIMAL DEGREES O R ROAD TYPES OR MILEPOST RD LOCATION ROAD TYPE

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1 PHOTOS TAKEN - -P - OTHER COUNTY * CITY * 5 VILL* TOWNSHIP * DEGREES / MINUTES / SECONDS LATITUDE TRAIC CRASH REPORT LOCAL INORMATION PDO UNDER STATE REPORTABLE DOLLAR AMOUNT PRIVATE PROPERTY CITY, VILL, TOWNSHIP * REPORTING NCY NCIC * MEDINA (TOWNSHIP O) LONGITUDE - REPORTING NCY NAME * MEDINA TWP. POLICE O R DECIMAL DEGREES LATITUDE * CRASH DATE * /7/ NUMBER O UNITS TIME O CRASH LONGITUDE : CRASH SEVERITY - ATAL - INJURY -PDO UNIT IN ERROR 0 HIT/SKIP - SOLVED. UNSOLVED 98 - ANIMAL DAY O WEEK THU WAY DIVISION DIVIDED UNDIVIDED DIVIDED LANE DIRECTION O TRAVEL N - NORTHBOUND E - EASTBOUND S - SOUTHBOUND W -WESTBOUND NUMBER O THRU LANES S OR MILEPOST AL - ALLEY CR - CIRCLE AV - AVENUE CT - COURT BL - BOULEVARD DR - DRIVE HE - HEIGHTS HW - HIGHWAY LA - LANE MP - MILEPOST PK - PARKWAY PI - PIKE PL - PLACE RD - SQ - SQUARE ST - STREET TE - TERRACE TL - TRAIL WA - WAY LOCATION ROUTE DISTANCE ROM REERENCE MILES EET YARDS LOCATION ROUTE NUMBER DIR ROM RE O LOC PREI REERENCE POINT CRASH LOCATION USED 0 - NOT AN INTERSECTION -INTERSECTION 0 - OUR-WAY INTERSECTION -MILE POST T-INTERSECTION -HOUSE NUMBER - Y-INTERSECTION CONTOUR - STRAIGHT LEVEL - STRAIGHT GRADE - CURVE LEVEL - TRAIC CIRCLE/ ROUNDABOUT - CURVE GRADE LOCATION NAME MEDINA REERENCE REERENCE ROUTE NUMBER ROUTE S 0 - IVE-POINT, OR MORE 07 - ON RAMP 08 - O RAMP - CROSSOVER 0 - DRIVEWAY/ ALLEY ACCESS 0 - DRY 0 - WET 0 - SNOW - ICE RE PREI RD LOCATION ROUTE S IR - INTERSTATE ROUTE (INC. TURNPIKE) US - US ROUTE SR - STATE ROUTE REERENCE NAME (, MILEPOST, HOUSE #) CR - NUMBERED COUNTY ROUTE TR - NUMBERED TOWNSHIP ROUTE DR REERENCE SHADY BROOKE - RAILWAY GRADE CROSSING - SHARED-USE PATHS OR TRAILS - SAND, MUD, DIRT, OIL, GRAVEL - WATER (STANDING, MOVING) 07 - SLUSH 08 - DEBRIS * INTERSECTION LOCATION O IRST HARMUL - ON WAY - ON SHOULDER - IN MEDIAN - ON SIDE 5 - ON GORE 6 - OUTSIDE TRAICWAY - RUT, HOLES, BUMPS, UNEVEN PAVEMENT* 0 - OTHER * ONLY MANNER O CRASH COLLISION/IMPACT WEATHER - NOT COLLISION BETWEEN TWO MOTOR VEHICLES IN TRANSPORT - REAR-END - HEAD-ON - REAR-TO-REAR 5 - BACKING 8 - SIDESWIPE, OPPOSITE DIRECTION 6 - ANGLE 7 - SIDESWIPE, SAME DIRECTION - CLEAR - CLOUDY - OG,SMOG,SMOKE - RAIN 5 - SLEET, HAIL 6 - SNOW 7 - SEVERE CROSSWINDS 8 - BLOWING SAND,SOIL, DIRT, SNOW 9 - OTHER/UNKNOWN SURACE - CONCRETE - BLACKTOP, BITUMINOUS, ASPHALT - BRICK/BLOCK - SLAG, GRAVEL, STONE 5 - DIRT 6 - OTHER LIGHT S - DAYLIGHT - DAWN - DUSK - DARK - LIGHTED WAY 5 - DARK - WAY NOT LIGHTED 6 - DARK - UNKNOWN WAY LIGHTING 7 - GLARE* 8 - OTHER * ONLY SCHOOL ZONE SCHOOL BUS YES, SCHOOL BUS DIRECTLY INVOLVED YES, SCHOOL BUS INDIRECTLY INVOLVED WORK ZONE WORKERS PRESENT LAW ENORCEMENT PRESENT (OICER/VEHICLE) LAW ENORCEMENT PRESENT (VEHICLE ONLY ) O WORK ZONE - L ANE CLOSURE - LANE SHIT/ CROSSOVER - WORK ON SHOULDER OR MEDIAN - INTERMITTENT OR MOVING WORK LOCATION O CRASH IN WORK ZONE - BEORE THE IRST WORK ZONE WARNING SIGN - ADVANCE WARNING AREA - TRANSITION AREA - ACTIVITY AREA 5 - TERMINATION AREA NARRATIVE UNIT # REAR-ENDED UNIT # WHILE STOPPED AT THE RED-LIGHT. UNIT # SAID HE HAD WORKED A LONG SHIT OVER-NIGHT WHICH PROBABLY HELPED CONTRIBUTE TO THE CRASH. UNIT # DRIVER TOOK DAUGHTERS TO DOCTORS OICE JUST TO CLEAR ANY CONCERNS. END REPORT TAKEN BY POLICE NCY SUPPLEMENT (CORRECTION OR ADDITION TO AN EISTING REPORT SENT TO ODPS) DATE CRASH REPORTED TIME CRASH REPORTED DISPATCH TIME ARRIVAL TIME TIME CLEARED OTHER INVESTIGATION TIME TOTAL MINUTES /7/ :0 OICER'S NAME* OICER CLI NICHOLSON :0 :50 OICER'S BADGE NUMBER 59 : CHECKED BY Page of 5

2 UNIT OWNER NAME: LAST, IRST, MIDDLE (SAME AS DRIVER) OWNER PHONE NUMBER - INC, AREA C (SAME AS DRIVER ) DAM SCALE DAM AREA 0 MEYERS, MARK OWNER ADDRESS: CITY, STATE, ZIP (SAME AS DRIVER ) 0 W NORTH ST MEDINA 56 LP STATE LICENSE PLATE NUMBER (0)0-990 VEHICLE IDENTIICATION NUMBER #OCCUPANTS - NONE - MINOR RONT 0 0 GA8 J5655WH7070 -UNCTIONAL 08 0 VEHICLE YEAR 998 VEHICLE MAKE SUBARU VEHICLE MODEL ORESTER VEHICLE COLOR BLACK - DISABLING PROO O INSURANCE SHOWN CARRIER NAME,,,,,, US DOT HM PLACARD ID NO. INSURANCE COMPANY PROGRESSIVE HM CLASS NUMBER VEHICLE WEIGHT GVWR/GCWR - LESS THAN OR EQUAL TO 0K LBS. - 0,00 TO 6,000 LBS - MORE THAN 6,000 LBS. HAZARDOUS MATERIAL RELEASED POLICY NUMBER CARGO BODY 0 - NO CARGO BODY /NOT APPLICABLE - POLE BUS/ VAN (9-5 SEATS, INC DRIVER) 0 - BUS (6+ SEATS, INC DRIVER) - VEHICLE TOWING ANOTHER VEHICLE - LOGGING - INTERMODAL CONTAINER CHASSIS 07 - CARGO VAN/ENCLOSED BO 08 - GRAIN, CHIPS, GRAVEL TOWED BY 0 - CARGO TANK - LAT BED - DUMP - CONCRETE MIER - AUTO TRANSPORTER 5 - GARB /REUSE 07 REAR CARRIER PHONE - INCLUDE AREA CODE TRAICWAY DESCRIPTION - T WO-WAY, NOT DIVIDED - T WO-WAY, NOT DIVIDED, CONTINUOUS LET TURN LANE - T WO-WAY, DIVIDED, UNPROTECTED(PAINTED OR GRASS >T.) MEDIAN - T WO-WAY, DIVIDED, POSITIVE MEDIAN BARRIER 5 - ONE-WAY TRAICWAY HIT / SKIP UNIT LOCATION PRIOR TO IMPACT 0 - INTERSECTION - MARKED CROSSWALK 0 - INTERSECTION - NO CROSSWALK 0 - INTERSECTION OTHER - MIDBLOCK - MARKED CROSSWALK - TRAVEL LANE - OTHER LOCATION - BICYCLE LANE 07 - SHOULDER/SIDE 08 - SIDEWALK - MEDIAN/CROSSING ISLAND 0 - DRIVEWAY ACCESS - SHARED-USE PATH OR TRAIL - NON-TRAICWAY AREA SPECIAL UNCTION 0 - NONE 0 - TAI 0 - RENTAL TRUCK (OVER 0K LBS) 0 - BUS - SCHOOL (PUBLIC OR PRIVATE) - BUS - TRANSIT - BUS - CHARTER 07 - BUS - SHUTTLE 08 - BUS - OTHER O USE - PERSONAL - COMMERCIAL - GOVERNMENT IN EMERGENCY RESPONSE UNIT OR HIT/SKIP - AMBULANCE 0 - IRE - HIGHWAY/MAINTENANCE - MILITARY - POLICE - PUBLIC UTILITY GOVERNMENT 6 - CONSTRUCTION EQUIP. PASSENGER VEHICLES (LESS THAN 9 PASSENGERS) 0 - SUB -COMPACT 0 - COMPACT 0 - MID SIZE - ULL SIZE - MINIVAN - SPORT UTILITY VEHICLE 07 - PICKUP 08 - VAN MOTORIZED BICYCLE - SNOWMOBILE/ATV - OTHER PASSENGER VEHICLE 7 - ARM VEHICLE 8 - ARM EQUIPMENT 9 - MOTORHOME 0 - GOL CART - TRAIN - OTHER (EPLAIN IN NARRATIVE) MOST DAMD AREA 0 IMPACT AREA 0 MED/HEAVY TRUCKS OR COMBO UNITS > 0K LBS - SINGLE UNIT TRUCK OR VAN ALE, 6 TIRES - SINGLE UNIT TRUCK ; + ALES 5 - SINGLE UNIT TRUCK / TRAILER 6 - TRUCK/TRACTOR (BOBTAIL) 7 - TRACTOR/SEMI-TRAILER 8 - TRACTOR/DOUBLE 9 - TRACTOR/TRIPLES 0 - OTHER MED/HEAVY VEHICLE 0 - NONE 0 - CENTER RONT 0 - RIGHT RONT - RIGHT SIDE - RIGHT REAR - REAR CENTER 07 - LET REAR HAS HM PLACARD 08 - LET SIDE - LET RONT 0 - TOP AND WINDOWS - UNDERCARRI - LOAD/TRAILER - TOTAL (ALL AREAS) - OTHER BUS/VAN/LIMO (9 OR MORE INCLUDING DRIVER) - BUS/VAN (9-5 SEATS,INC DRIVER) - BUS (6+ SEATS,INC DRIVER) - ANIMAL WITH RIDER - ANIMAL WITH BUGGY, WAGON, SURREY 5 - BICYCLE/PEDACYCLIST 6 - PEDESTRIAN/SKATER 7 - OTHER ACTION - NON- CONTACT - NON-COLLISION - STRIKING - STRUCK 5 - STRIKING/STRUCK PRE- CRASH ACTION STRAIGHT AHEAD 0 - BACKING 0 - CHANGING LANES - OVERTAKING/PASSING - MAKING RIGHT TURN - MAKING LET TURN 07 - MAKING U-TURN 08 - ENTERING TRAIC LANE - LEAVING TRAIC LANE 0 - PARKED - SLOWING OR STOPPED IN TRAIC - DRIVERLESS - NEGOTIATING A CURVE - OTHER ACTION 5 - ENTERING OR CROSSING SPECIIED LOCATION 6 - WALKING,RUNNING, JOGGING, PLAYING, CYCLING 7 - WORKING 8 - PUSHING VEHICLE 9 - APPROACHING OR LEAVING VEHICLE 0 - STANDING - OTHER ACTION CONTRIBUTING CIRCUMSTANCES 0 - NONE 0 - AILURE TO YIELD 0 - RAN RED LIGHT - RAN STOP SIGN - ECEEDED SPEED LIMIT - UNSAE SPEED 07 - IMPROPER TURN 08 - LET O CENTER - OLLOWED TOO CLOSELY/ACDA 0 - IMPROPER LANE CHANGE / PASSING/O SEQUENCE O S IRST MOST HARMUL HARMUL COLLISION WITH PERSON, VEHICLE OR OBJECT NOT IED - PEDESTRIAN 5 - PEDALCYCLE 6 - RAILWAY VEHICLE (TRAIN, ENGINE) 7 - ANIMAL - ARM 8 - ANIMAL - DEER 9 - ANIMAL - OTHER 0 - MOTOR VEHICLE IN TRANSPORT - IMPROPER BACKING - IMPROPER START ROM PARKED POSITION - STOPPED OR PARKED ILLEGALLY - OPERATING VEHICLE IN NEGLIGENT MANNER 5 - SWERVING TO AVOID (DUE TO ETERNAL 6 - WRONG SIDE/WRONG WAY 7 - AILURE TO CONTROL 8 - VISION OBSTRUCTION 9 - OPERATING DEECTIVE EQUIPMENT 0 - LOAD SHITING/ALLING/SPILLING - OTHER IMPROPER ACTION - PARKED MOTOR VEHICLE - WORK ZONE MAINTENANCE EQUIPMENT - STRUCK BY ALLING, SHITING CARGO OR ANYTHING SET IN MOTION B OR ANYTHING SET IN MOTION BY A MOTOR VEHICLE - OTHER MOVABLE OBJECT - NONE - IMPROPER CROSSING - DARTING 5 - LYING AND/OR ILLEGALLY IN WAY 6 - ALURE TO YIELD RIGHT O WAY 7 - NOT VISIBLE (DARK CLOTHING) 8 - INATTENTIVE 9 - AILURE TO OBEY TRAIC SIGNS /SIGNALS/OICER 0 - WRONG SIDE O THE - OTHER ACTION VEHICLE DEECTS NON-COLLISION S 0 - OVERTURN/ROLLOVER - EQUIPMENT AILURE (BLOWN TIRE, BRAKE AILURE, ETC) 0 - IRE/EPLOSION 07 - SEPARATION O UNITS 0 - IMMERSION 08 - RAN O RIGHT - JACKKNIE - RAN O LET - CARGO/EQUIPMENT LOSS OR SHIT COLLISION WITH IED OBJECT 5 - IMPACT ATTENUATOR/CRASH CUSHION - MEDIAN CABLE BARRIER 6 - BRIDGE OVERHEAD STRUCTURE 7 - BRIDGE PIER OR ABUTMENT 8 - BRIDGE PARAPET 9 - BRIDGE RAIL 0 - GUARDRAIL ACE - GUARDRAIL END - PORTABLE BARRIER - MEDIAN GUARDRAIL BARRIER 5 - MEDIAN CONCRETE BARRIER 6 - MEDIAN OTHER BARRIER 7 - TRAIC SIGN POST 8 - OVERHEAD SIGN POST 9 - LIGHT/LUMINARIES SUPPORT 0 - UTILITY POLE - OTHER POST, POLE OR SUPPORT - CULVERT - CURB - DITCH 5 - EMBANKMENT 6 - ENCE 7 - MAILBO 0 - TURN SIGNALS 0 - HEAD LAMPS 0 - TAIL LAMPS - BRAKES - STEERING - TIRE BLOWOUT 07 - WORN OR SLICK TIRES 08 - TRAILER EQUIPMENT DEECTIVE - MOTOR TROUBLE 0 - DISABLED ROM PRIOR ACCIDENT - OTHER DEECTS 0 - CROSS MEDIAN - CROSS CENTER LINE OPPOSITE DIRECTION O TRAVEL - DOWNHILL RUNAWAY - OTHER NON-COLLISION 8 - TREE 9 - IRE HYDRANT 50 - WORK ZONE MAINTENANCE EQUIPMENT 5 - WALL, BUILDING, TUNNEL IED OBJECT UNIT SPEED 5 STATED ESTIMATED POSTED SPEED 0 TRAIC CONTROL 0 - NO CONTROLS 0 - STOP SIGN 0 - YIELD SIGN - TRAIC SIGNAL - TRAIC LASHERS - SCHOOL ZONE 07 - RAIL CROSSBUCKS - CROSSWALK LINES 08 - RAIL LASHERS - WALK/DON'T WALK - RAIL GATES 0 - CONSTRUCTION BARRICADE 6 - NOT REPORTED - PERSON (LAGGER, OICER) - PAVEMENT MARKINGS UNIT DIRECTION ROM TO - NORTH - SOUTH - EAST - WEST 5 - NORTHEAST 6 - NORTHWEST 7 - SOUTHEAST 8 - SOUTHWEST Page of 5

3 UNIT OWNER NAME: LAST, IRST, MIDDLE (SAME AS DRIVER) OWNER PHONE NUMBER - INC, AREA C (SAME AS DRIVER ) DAM SCALE DAM AREA 0 WASOWSKI, JENNI OWNER ADDRESS: CITY, STATE, ZIP (SAME AS DRIVER ) 99 W ABBEY DRIVE MEDINA 56 LP STATE LICENSE PLATE NUMBER (0)0-995 VEHICLE IDENTIICATION NUMBER #OCCUPANTS - NONE - MINOR RONT 0 0 VEHICLE YEAR 008 PROO O INSURANCE SHOWN EWW658 VEHICLE MAKE KIA MOTORS CORPORATION CARRIER NAME,,,,,, US DOT HM PLACARD ID NO. INSURANCE COMPANY LIBERTY MUTUAL HM CLASS NUMBER VEHICLE WEIGHT GVWR/GCWR - LESS THAN OR EQUAL TO 0K LBS. - 0,00 TO 6,000 LBS - MORE THAN 6,000 LBS. HAZARDOUS MATERIAL RELEASED KNDMB860 CARGO BODY 0 - NO CARGO BODY /NOT APPLICABLE - POLE 0 VEHICLE MODEL SEDONA POLICY NUMBER A BUS/ VAN (9-5 SEATS, INC DRIVER) 0 - BUS (6+ SEATS, INC DRIVER) - VEHICLE TOWING ANOTHER VEHICLE - LOGGING - INTERMODAL CONTAINER CHASSIS 07 - CARGO VAN/ENCLOSED BO 08 - GRAIN, CHIPS, GRAVEL TOWED BY VEHICLE COLOR BLUE 0 - CARGO TANK - LAT BED - DUMP - CONCRETE MIER - AUTO TRANSPORTER 5 - GARB /REUSE -UNCTIONAL - DISABLING REAR CARRIER PHONE - INCLUDE AREA CODE TRAICWAY DESCRIPTION - T WO-WAY, NOT DIVIDED - T WO-WAY, NOT DIVIDED, CONTINUOUS LET TURN LANE - T WO-WAY, DIVIDED, UNPROTECTED(PAINTED OR GRASS >T.) MEDIAN - T WO-WAY, DIVIDED, POSITIVE MEDIAN BARRIER 5 - ONE-WAY TRAICWAY HIT / SKIP UNIT LOCATION PRIOR TO IMPACT 0 - INTERSECTION - MARKED CROSSWALK 0 - INTERSECTION - NO CROSSWALK 0 - INTERSECTION OTHER - MIDBLOCK - MARKED CROSSWALK - TRAVEL LANE - OTHER LOCATION - BICYCLE LANE 07 - SHOULDER/SIDE 08 - SIDEWALK - MEDIAN/CROSSING ISLAND 0 - DRIVEWAY ACCESS - SHARED-USE PATH OR TRAIL - NON-TRAICWAY AREA SPECIAL UNCTION 0 - NONE 0 - TAI 0 - RENTAL TRUCK (OVER 0K LBS) 0 - BUS - SCHOOL (PUBLIC OR PRIVATE) - BUS - TRANSIT - BUS - CHARTER 07 - BUS - SHUTTLE 08 - BUS - OTHER O USE - PERSONAL - COMMERCIAL - GOVERNMENT IN EMERGENCY RESPONSE UNIT OR HIT/SKIP - AMBULANCE 0 - IRE - HIGHWAY/MAINTENANCE - MILITARY - POLICE - PUBLIC UTILITY GOVERNMENT 6 - CONSTRUCTION EQUIP. PASSENGER VEHICLES (LESS THAN 9 PASSENGERS) 0 - SUB -COMPACT 0 - COMPACT 0 - MID SIZE - ULL SIZE - MINIVAN - SPORT UTILITY VEHICLE 07 - PICKUP 08 - VAN MOTORIZED BICYCLE - SNOWMOBILE/ATV - OTHER PASSENGER VEHICLE 7 - ARM VEHICLE 8 - ARM EQUIPMENT 9 - MOTORHOME 0 - GOL CART - TRAIN - OTHER (EPLAIN IN NARRATIVE) MOST DAMD AREA IMPACT AREA MED/HEAVY TRUCKS OR COMBO UNITS > 0K LBS - SINGLE UNIT TRUCK OR VAN ALE, 6 TIRES - SINGLE UNIT TRUCK ; + ALES 5 - SINGLE UNIT TRUCK / TRAILER 6 - TRUCK/TRACTOR (BOBTAIL) 7 - TRACTOR/SEMI-TRAILER 8 - TRACTOR/DOUBLE 9 - TRACTOR/TRIPLES 0 - OTHER MED/HEAVY VEHICLE 0 - NONE 0 - CENTER RONT 0 - RIGHT RONT - RIGHT SIDE - RIGHT REAR - REAR CENTER 07 - LET REAR HAS HM PLACARD 08 - LET SIDE - LET RONT 0 - TOP AND WINDOWS - UNDERCARRI - LOAD/TRAILER - TOTAL (ALL AREAS) - OTHER BUS/VAN/LIMO (9 OR MORE INCLUDING DRIVER) - BUS/VAN (9-5 SEATS,INC DRIVER) - BUS (6+ SEATS,INC DRIVER) - ANIMAL WITH RIDER - ANIMAL WITH BUGGY, WAGON, SURREY 5 - BICYCLE/PEDACYCLIST 6 - PEDESTRIAN/SKATER 7 - OTHER ACTION - NON- CONTACT - NON-COLLISION - STRIKING - STRUCK 5 - STRIKING/STRUCK PRE- CRASH ACTION 0 - STRAIGHT AHEAD 0 - BACKING 0 - CHANGING LANES - OVERTAKING/PASSING - MAKING RIGHT TURN - MAKING LET TURN 07 - MAKING U-TURN 08 - ENTERING TRAIC LANE - LEAVING TRAIC LANE 0 - PARKED - SLOWING OR STOPPED IN TRAIC - DRIVERLESS - NEGOTIATING A CURVE - OTHER ACTION 5 - ENTERING OR CROSSING SPECIIED LOCATION 6 - WALKING,RUNNING, JOGGING, PLAYING, CYCLING 7 - WORKING 8 - PUSHING VEHICLE 9 - APPROACHING OR LEAVING VEHICLE 0 - STANDING - OTHER ACTION CONTRIBUTING CIRCUMSTANCES NONE 0 - AILURE TO YIELD 0 - RAN RED LIGHT - RAN STOP SIGN - ECEEDED SPEED LIMIT - UNSAE SPEED 07 - IMPROPER TURN 08 - LET O CENTER - OLLOWED TOO CLOSELY/ACDA 0 - IMPROPER LANE CHANGE / PASSING/O SEQUENCE O S IRST MOST HARMUL HARMUL COLLISION WITH PERSON, VEHICLE OR OBJECT NOT IED - PEDESTRIAN 5 - PEDALCYCLE 6 - RAILWAY VEHICLE (TRAIN, ENGINE) 7 - ANIMAL - ARM 8 - ANIMAL - DEER 9 - ANIMAL - OTHER 0 - MOTOR VEHICLE IN TRANSPORT - IMPROPER BACKING - IMPROPER START ROM PARKED POSITION - STOPPED OR PARKED ILLEGALLY - OPERATING VEHICLE IN NEGLIGENT MANNER 5 - SWERVING TO AVOID (DUE TO ETERNAL 6 - WRONG SIDE/WRONG WAY 7 - AILURE TO CONTROL 8 - VISION OBSTRUCTION 9 - OPERATING DEECTIVE EQUIPMENT 0 - LOAD SHITING/ALLING/SPILLING - OTHER IMPROPER ACTION - PARKED MOTOR VEHICLE - WORK ZONE MAINTENANCE EQUIPMENT - STRUCK BY ALLING, SHITING CARGO OR ANYTHING SET IN MOTION B OR ANYTHING SET IN MOTION BY A MOTOR VEHICLE - OTHER MOVABLE OBJECT - NONE - IMPROPER CROSSING - DARTING 5 - LYING AND/OR ILLEGALLY IN WAY 6 - ALURE TO YIELD RIGHT O WAY 7 - NOT VISIBLE (DARK CLOTHING) 8 - INATTENTIVE 9 - AILURE TO OBEY TRAIC SIGNS /SIGNALS/OICER 0 - WRONG SIDE O THE - OTHER ACTION VEHICLE DEECTS NON-COLLISION S 0 - OVERTURN/ROLLOVER - EQUIPMENT AILURE (BLOWN TIRE, BRAKE AILURE, ETC) 0 - IRE/EPLOSION 07 - SEPARATION O UNITS 0 - IMMERSION 08 - RAN O RIGHT - JACKKNIE - RAN O LET - CARGO/EQUIPMENT LOSS OR SHIT COLLISION WITH IED OBJECT 5 - IMPACT ATTENUATOR/CRASH CUSHION - MEDIAN CABLE BARRIER 6 - BRIDGE OVERHEAD STRUCTURE 7 - BRIDGE PIER OR ABUTMENT 8 - BRIDGE PARAPET 9 - BRIDGE RAIL 0 - GUARDRAIL ACE - GUARDRAIL END - PORTABLE BARRIER - MEDIAN GUARDRAIL BARRIER 5 - MEDIAN CONCRETE BARRIER 6 - MEDIAN OTHER BARRIER 7 - TRAIC SIGN POST 8 - OVERHEAD SIGN POST 9 - LIGHT/LUMINARIES SUPPORT 0 - UTILITY POLE - OTHER POST, POLE OR SUPPORT - CULVERT - CURB - DITCH 5 - EMBANKMENT 6 - ENCE 7 - MAILBO 0 - TURN SIGNALS 0 - HEAD LAMPS 0 - TAIL LAMPS - BRAKES - STEERING - TIRE BLOWOUT 07 - WORN OR SLICK TIRES 08 - TRAILER EQUIPMENT DEECTIVE - MOTOR TROUBLE 0 - DISABLED ROM PRIOR ACCIDENT - OTHER DEECTS 0 - CROSS MEDIAN - CROSS CENTER LINE OPPOSITE DIRECTION O TRAVEL - DOWNHILL RUNAWAY - OTHER NON-COLLISION 8 - TREE 9 - IRE HYDRANT 50 - WORK ZONE MAINTENANCE EQUIPMENT 5 - WALL, BUILDING, TUNNEL IED OBJECT UNIT SPEED 0 STATED ESTIMATED POSTED SPEED 0 TRAIC CONTROL 0 - NO CONTROLS 0 - STOP SIGN 0 - YIELD SIGN - TRAIC SIGNAL - TRAIC LASHERS - SCHOOL ZONE 07 - RAIL CROSSBUCKS - CROSSWALK LINES 08 - RAIL LASHERS - WALK/DON'T WALK - RAIL GATES 0 - CONSTRUCTION BARRICADE 6 - NOT REPORTED - PERSON (LAGGER, OICER) - PAVEMENT MARKINGS UNIT DIRECTION ROM TO - NORTH - SOUTH - EAST - WEST 5 - NORTHEAST 6 - NORTHWEST 7 - SOUTHEAST 8 - SOUTHWEST Page of 5

4 / / OCCUPANT Motorist / Non-Motorist Motorist / Non-Motorist 0 0 W North St,,Medina,,56 OL STATE 0 99 W Abbey Drive,,Medina,,56 OL STATE INJURED TAKEN BY EMS NCY MEDICAL ACILITY INJURED TAKEN TO SAETY EQUIPMENT USED INJURED TAKEN BY EMS NCY MEDICAL ACILITY INJURED TAKEN TO SAETY EQUIPMENT USED NAME: LAST, IRST, MIDDLE Meyers,Mark, OPERATOR LICENSE NUMBER SC7580 OENSE CHARGED ( LOCAL CODE) 5.A NAME: LAST, IRST, MIDDLE Wasowski,Jenni, OPERATOR LICENSE NUMBER RP596 OENSE CHARGED ( LOCAL CODE) OL CLASS OL CLASS NO VALID OL OENSE DESCRIPTION NO VALID OL M/C END M/C END 5 ALCOL/DRUG SUSPECTED ALCOL/DRUG SUSPECTED CITATION NUMBER x5 VALUE OENSE DESCRIPTION CITATION NUMBER HANDS-REE DEVICE USED DATE O BIRTH /07/98 DOT COMPLIANT DATE O BIRTH /9/975 DOT COMPLIANT (0)0-990 SEATING POSITION 0 VALUE (0)0-995 SEATING POSITION 0 HANDS-REE DEVICE USED DRUG TEST 9 8 DRUG TEST M - EMALE - EMALE INJURED TAKEN BY SAETY EQUIPMENT USED SAETY EQUIPMENT - NO INJURY / NONE REPORTED - POSSIBLE - NON-INCAPACITATING - INCAPACITATING 5 - ATAL - NOT TRANSPORTED / TREATED AT SCENE - EMS - POLICE - OTHER 0 - NONE USED - VEHICLE OCCUPANT 0 - SHOULDER BELT ONLY USED 0 - LAP BELT ONLY USED - SHOULDER AND LAP BELT ONLY USED - CHILD RESTRAINT SYSTEM-ORWARD ACING - CHILD RESTRAINT SYSTEM-REAR ACING 07 - BOOSTER SEAT 08 - USED - NONE USED 0 - USED - PROTECTIVE PADS USED (ELBOWS, KNEES, ETC) - RELECTIVE Clothing - LIGHTING - OTHER SEATING POSITION AIR BAG US 0 - RONT - LET SIDE ( DRIVER) 0 - RONT - MIDDLE 0 - RONT - RIGHT SIDE - SECOND - LET SIDE ( PASSENGER) - SECOND - MIDDLE - SECOND - RIGHT SIDE 07 - THIRD - LET SIDE ( SIDE CAR) 08 - THIRD - MIDDLE - THIRD - RIGHT SIDE 0 - SLEEPER SECTION O CAB (TRUCK) - PASSENGER IN OTHER ENCLOSED CARGO AREA (NON-TRAILING UNIT SUCH AS A BUS, PICK-UP WITH CAP) - PASSENGER IN UNENCLOSED CARGO AREA - TRAILING UNIT - RIDING ON VEHICLE ETERIOR (NON-TRAILING UNIT) OTHER - NOT DEPLOYED - DEPLOYED RONT - DEPLOYED SIDE - DEPLOYED BOTH RONT/SIDE 5 - NOT APPLICABLE 9 - DEPLOYMENT UNKNOWN EJECTION TRAPPED OPERATOR LICENSE CLASS ALCOL/DRUG SUSPECTED - NOT EJECTED - TOTALLY EJECTED - PARTIALLY EJECTED - NOT APPLICABLE - NOT TRAPPED - ETRICATED BY - ETRICATED BY NON- - CLASS A - CLASS B - CLASS C - APPARENTLY NORMAL - PHYSICAL IMPAIRMENT - EMOTIONAL (DEPRESSED, ANGRY, DISTURBED) 5 - ELL ASLEEP, AINTED, ATIGUED 6 - UNDER THE INLUENCE O MEDICATIONS, DRUGS, ALCOL - NONE - YES - ALCOL SUSPECTED - YES -HBD NOT IMPAIRED - REGULAR CLASS (IO IS "D") 5 - MC/MOPED ONLY - ILLNESS 7 - OTHER - YES -DRUGS SUSPECTED 5 - YES -ALCOL AND DRUGS SUSPECTED TYP DRUG TEST - NONE GIVEN - TEST REUSED - TEST GIVEN, CONTAMINATED SAMPLE/UNUSABLE - TEST GIVEN, RESULTS KNOWN - NONE - BLOOD - URINE - BREATH - NONE GIVEN - TEST REUSED - TEST GIVEN, CONTAMINATED SAMPLE/UNUSABLE - TEST GIVEN, RESULTS KNOWN - NONE - BLOOD - URINE - OTHER - NO DISTRACTION REPORTED - PHONE - TETING / ING - ELECTRONIC COMMUNICATION DEVIC ELECTRONIC DEVICE (NAVIGATION DEVICE, RADIO, DVD) 6 - OTHER INSIDE THE VEHICLE 7 - ETERNAL DISTRACTION Occupant Occupant INJURED TAKEN BY EMS NCY MEDICAL ACILITY INJURED TAKEN TO SAETY EQUIPMENT USED 99 W Abbey Drive,, Medina,,56 INJURED TAKEN BY EMS NCY MEDICAL ACILITY INJURED TAKEN TO SAETY EQUIPMENT USED NAME: LAST, IRST, MIDDLE Wasowski, Jane, 99 W Abbey Drive,, Medina,,56 NAME: LAST, IRST, MIDDLE Wasowski, Julie, DATE O BIRTH 0//00 DOT COMPLIANT DATE O BIRTH 0/8/0 DOT COMPLIANT (6)0-995 SEATING POSITIO 0 (6)0-995 SEATING POSITIO - EMALE - EMALE Page of 5

5 / ADDENDUM INJURED TAKEN BY SAETY EQUIPMENT USED SAETY EQUIPMENT - NO INJURY / NONE REPORTED - POSSIBLE - NON-INCAPACITATING - INCAPACITATING 5 - ATAL - NOT TRANSPORTED / TREATED AT SCENE - EMS - POLICE - OTHER 0 - NONE USED - VEHICLE OCCUPANT 0 - SHOULDER BELT ONLY USED 0 - LAP BELT ONLY USED - SHOULDER AND LAP BELT ONLY USED - CHILD RESTRAINT SYSTEM-ORWARD ACING - CHILD RESTRAINT SYSTEM-REAR ACING 07 - BOOSTER SEAT 08 - USED - NONE USED 0 - USED - PROTECTIVE PADS USED (ELBOWS, KNEES, ETC) - RELECTIVE Clothing - LIGHTING - OTHER SEATING POSITION AIR BAG US 0 - RONT - LET SIDE ( DRIVER) 0 - RONT - MIDDLE 0 - RONT - RIGHT SIDE - SECOND - LET SIDE ( PASSENGER) - SECOND - MIDDLE - SECOND - RIGHT SIDE 07 - THIRD - LET SIDE ( SIDE CAR) 08 - THIRD - MIDDLE - THIRD - RIGHT SIDE 0 - SLEEPER SECTION O CAB (TRUCK) - PASSENGER IN OTHER ENCLOSED CARGO AREA (NON-TRAILING UNIT SUCH AS A BUS, PICK-UP WITH CAP) - PASSENGER IN UNENCLOSED CARGO AREA - TRAILING UNIT - RIDING ON VEHICLE ETERIOR (NON-TRAILING UNIT) OTHER - NOT DEPLOYED - DEPLOYED RONT - DEPLOYED SIDE - DEPLOYED BOTH RONT/SIDE 5 - NOT APPLICABLE 9 - DEPLOYMENT UNKNOWN EJECTION TRAPPED OPERATOR LICENSE CLASS ALCOL/DRUG SUSPECTED - NOT EJECTED - TOTALLY EJECTED - PARTIALLY EJECTED - NOT APPLICABLE - NOT TRAPPED - ETRICATED BY - ETRICATED BY NON- - CLASS A - APPARENTLY NORMAL - CLASS B - PHYSICAL IMPAIRMENT - CLASS C - EMOTIONL (DEPRESSED, ANGRY, DISTURBED) - REGULAR CLASS (IO IS "D") - ILLNESS 5 - MC/MOPED ONLY 5 - ELL ASLEEP, AINTED, ATIGUED 6 - UNDER THE INLUENCE O MEDICATIONS, DRUGS, ALCOL 7 - OTHER - NONE - YES - ALCOL SUSPECTED - YES -HBD NOT IMPAIRED - YES -DRUGS SUSPECTED 5 - YES -ALCOL AND DRUGS SUSPECTED TYP DRUG TEST - NONE GIVEN - TEST REUSED - TEST GIVEN, CONTAMINATED SAMPLE/UNUSABLE - TEST GIVEN, RESULTS KNOWN - NONE - BLOOD - URINE - BREATH - NONE GIVEN - TEST REUSED - TEST GIVEN, CONTAMINATED SAMPLE/UNUSABLE - TEST GIVEN, RESULTS KNOWN - NONE - BLOOD - URINE - OTHER - NO DISTRACTION REPORTED - PHONE - TETING / ING - ELECTRONIC COMMUNICATION DEVIC ELECTRONIC DEVICE (NAVIGATION DEVICE, RADIO, DVD) 6 - OTHER INSIDE THE VEHICLE 7 - ETERNAL DISTRACTION Page 5 of 5