Accident Number

15036070500

Agency NCIC No.

APD0000

Date
02/05/2015

Time
06:55

Day Of Week
THURSDAY

GEORGIA UNIFORM MOTOR VEHICLE

ACCIDENT REPORT
Injuries
1

Vehicles
1

Off. Arrived
07:05

County
FULTON

Fatalities
0

Date Rec. by DOT

Inside City Of:

Atlanta

Hit And Run?

Suppl. To Original?

Road of Occurence 510 WHITEHALL ST

At Its Intersection With MC DANIELS ST

Last Name
HENRY

UNIT 1 - DRIVER

First
EBONI

Address
2106 HILDA BURNS
State

City
LITHONIA

Driver's License No

Class

State

058123490

CLASS D

GA

Insurance Co.

UNIT 2 - PEDESTRIAN

Last Name
KATZ

First
BECKY

Middle

Address
923 OAKHILL SW

GA

Posted
30
Speed

Middle
JENNETTE

Private Property?

Zip

DOB

City

State

Zip

DOB

30058

04/28/1997

ATL

GA

30310

09/14/1986

Male

Female

Policy No.

Driver's License No

Class

State

059225424

CLASS C

GA

Posted
Speed

STATE FARM MUTUAL

AUTOMOB

Year

Make

Model

Telephone No.

2005

NISS

SEN

678-469-6778

VIN
3N1CB51D35L479940

Insurance Co.

Year

Make

Male

Female

Policy No.
Model

Telephone No.
914-643-5036

Vehicle Color

VIN

Vehicle Color

Silver

Tag #

State

County

Year

KEI 3

GA

DEKALB

Tag #

Trailer

State

County

Year

Trailer

Same as
Driver

Owner's Last Name

First

Middle

HENRY

KOLANDRA

DIONNE

Address
2106 HILDA BURNS
City

State

Zip

LITHONIA

GA

30058

Owner's Last Name

Same as
Driver

First

Middle

Address

Removed By

Request

City

State

Removed By

List

Zip

Request

List

THE MOM MS. KOLANDRA

Alcohol Test

Type

Results

Drug Test

No

Not Tested

None Given

No

Driver Cond

Type

Results

Direction of Travel

Vision Obscured Contributing Factors

Not Obscured

Vehicle Cond

Vehicle Maneuver

Ped Maneuver

No Known Defects

Straight

Type

Results

Drug Test

Not Tested

None Given

No

Driver Cond

Direction of Travel

Other

Type

Vehicle Cond

Results

Vision Obscured Contributing Factors

Unknown or NA

Other

Ped Maneuver

Vehicle Maneuver

Other

Most Harmful Event

Vehicle Class

Vehicle Type:

Pedestrian

Privately Owned

Passenger Car

Traffic Ctrl Lanes

Device Inoperative?

Yes

Injured Taken To :

No

By:

EMS Notified Time

Hospital Arrival Time

Alcohol Test
No

Yes

No

Vehicle Class

Vehicle Type:

Traffic Ctrl Lanes

Device Inoperative?

Yes

Injured Taken To :

EMS Arrival Time

Photos
Taken

Most Harmful Event

EMS Notified Time

Hospital Arrival Time

By:

No

By:
EMS Arrival Time
Photos
Taken

Commercial Vehicles Only

Yes

No

By:

Commercial Vehicles Only

Carrier Name

Carrier Name

Vehicle #
Address

No. of Axles

G.V.W.R

City

Vehicle Config.

I.C.C.M.C. #

Zip

Vehicle #
Address

State
Fed. Reportable
Yes
No

Cargo Body Type

No. of Axles

G.V.W.R

U.S. D.O.T. #

Interstate

City

Vehicle Config.

I.C.C.M.C. #

State

Zip

Fed. Reportable
Yes
No

Cargo Body Type

Interstate

U.S. D.O.T. #

Intrastate
C.D.L. ?
Vehicle Placarded ?
Released ?

Yes
Yes
Yes

No
No

C.D.L. Suspended?
Hazardous Materials?

Intrastate

Yes

No

C.D.L. ?

Yes

No

C.D.L. Suspended?

Yes

No

Yes

No

Vehicle Placarded ?

Yes

No

Hazardous Materials?

Yes

No

Released ?

Yes

No

No

If YES, Name or 4 Digit Number from Diamond

Box:
Cargo Loss or Shift
Ran Off Road
Down Hill Runaway

Separation of
Units

If YES, Name or 4 Digit Number from Diamond

Box:
Cargo Loss or Shift
Ran Off Road
Down Hill Runaway

Separation of
Units

Officer Information
Report By:

Badge #

Department

Report Date

NEEDS FIXED

5031

ATLPD

2/23/2015 9:50:27 AM ATLANTA TRANSMIT

Date of Print: 2/23/2015 9:50:44 AM | 5193085

Submitted By

Checked By

Date Checked
2/20/2015
Page 1 of 4

Witnesses
None Listed

Remarks

Driver #1 Ms. HENRY, EBONI of the silver 2005 Nissan Sentra Georgia tag # KEI3 stated she was driving east bound in the
right lane on Whitehall Street SW just before Mcdaniel street SW, when a dark color possible Green SUV that was in front of her
suddenly pulled into the left lane. Driver #1 said she suddenly hit something, then she realize that it was a Pedestrian on a
Bicycle. Driver # 1 said everything happen so fast she did not see the Pedestrian on the bike.
The Female pedestrian Ms. KATZ, BECKY on a blue Cannondale R 500 CAD 3 Bicycle stated that she was RIDING IN
THE MIDDLE of the East Bound Lane on Whitehall street SW just before McDaniel street SW, when she was struck from behind.
She said, she fell to the roadway of her bike, she complain of left risk, neck and back pain with a small cut on her right ring
finger. Ms. KATZ was treated at the scene by Grady EMT 360, she was transported to Grady Hospital because of the extensive
damages to her Bicycle and the car. I examine the bike, it had a red light and reflectors on the back of it, there was a multicolor
bag with dark grey reflectors attached to the bike. The female rider had a blue helmet, and a blue Jacket with dark grey reflectors
on them.
The driver of the car did not report any injuries, she was arrested on a copy of charges for Driving on a suspended
license, suspension date 01/15/2015 with a court date of 02/26/2015 at 0800. Sergeant Daniel was advised. Her mother Ms.
Koylandra came to the scene and Ms. EBONI was released to her along with the vehicle.
Three witness who was in the area gave their name as Ms. FLETCHER, TERESIA FLETCHER,JERMILIA and
FLETCHER, INDIA Phone # 6786636491. They said the driver of the car continued driving after the accident and they went and
stop her. No other charges were made base on my investigation.

Date of Print: 2/23/2015 9:50:44 AM | 5193085

Page 2 of 4

Diagram

Citations
Unit

Name

Violation

EBONI JENNETTE
HENRY

40-5-121 (DRIVE W/LICENSE SUSP/REVOKED)

BECKY KATZ

None

Collision Information
First Harmful
Event

Traffic
Way Flow

Weather

Pedestrian

Two-Way
Clear
Trafficway with
no physical
separation

Date of Print: 2/23/2015 9:50:44 AM | 5193085

Surface Cond.

Light Cond.

Manner of
Collision

Location at
area of Impact

Road
Comp.

Road
Def.

Road
Character

Construction /
Maintenance Zone

Dry

Dawn

Rear End

On Roadway

Black Top

No
Defects

Straight and
Level

None

Page 3 of 4

Vehicle Information
VEH #

Number of Occupants

Point of Initial Contact

Damage To Vehicles

Skid Distance Before Impact

After

Width of Road

Right Side-Far Front

Extensive

Property Damage
None Listed

Involved Persons

Last Name

First

Address

City

S
t
a
t
e

HENRY

EBONI

2106 HILDA
BURNS

LITHONIA

GA

30058 17

KATZ

BECKY

923 OAKHILL ATL

SW

GA

30310 28

Date of Print: 2/23/2015 9:50:44 AM | 5193085

Zip

A
g
e

S
e
x

V
e
h
#

P
o
s
Front Seat-Left
Side

Injury

Taken
for
treat.

Eject

Not Injured

No

Not Ejected

Safety
Equip.
Lap and Shoulder
Belt

Extric
No

Air
Bag
Non-Deployed
Air Bag

Complaint

Page 4 of 4