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MV-104 (5/11) PAGE 1 of 2
Use the space marked VEHICLE 2 for the fourth vehicle, and mark it # 4 and so on. Additional forms are available at any Motor Vehicles office or from the DMV
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pedestrian/bicyclist/other pedestrian location
MV-104AN (5/04). *EXPLAIN IN ACCIDENT DESCRIPTION. If a question DOES NOT APPLY, enter a dash (-). If an answer is UNKNOWN, enter an X. P. Pedestrian. S
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MV104AN
MV104AN. APPARENT CONTRIBUTING FACTORS. Human. 2. Alcohol Involvement. 3. Backing Unsafely*. 4. Driver Inattention/Distraction*. 5. Driver Inexperience. 6.
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