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tr--------_ <br /> ' �i� '` `���t���.� <br /> � � <br /> � <br /> 'i YORT CLAIM FORM SCP 1 a 2013 <br /> , <br /> a a��.���09 C�7fY OF E'VE[�E'1"d' , <br /> Pursuant to Chapter 4.96 of tlie Revlsecl Code oF Washington (RCW), `']{3/ �,'I�'� <br /> ; this form Is for Flllny a tod daim against the Clty oF Everett. Somc of <br /> � the InFormallon requested on ttils form Is requlred by RCW 4.96.020 I <br /> and may be subJeci to publlc dlsdosure. 'fhe Clty Clerk Is ;he Clry's cllyClcikCloim No. <br /> ' deslgnated agent for the purposr of recelving clalms, UaJm /orms ,� �r� -13 <br /> cannotbesabmfttedelechnn/caUy(vJae-rna!/orfaxJ. ���30p'�J�JI <br /> I <br /> i <br /> , ..' . : ,; 'c �. < _. . •, -. . <br /> ! �..PLEASE TYFE��,OR PRIN,Y„C,L'EARI.Y.,IN•INK :?'.;�� . : . �. .,: ..� : �;- . ���.::`.;.;: <br /> Mall ar deliver original signed ctalm form to: Office of the Cfty Clerk <br /> � Clty of Everett ' <br /> Business Hourc: 2930 Wetmore Ave.,Ste, i-A <br /> Mon.—Frl.�8 a.m.to 6 p.m�,Paclflc Time EvereK�WA 98201 <br /> , closed on cfty holidays <br /> CLAIMANTINFORMATION: <br /> ' 1.Uaiment's namc: <br /> � Rtddell Kevin Davld 08/30/1971 <br /> lnstname Flrst M/dA/e Os1r.ofG/rNr(mm/dJ/yyyy) <br /> �, <br /> 2, a�rmnt msldentlal address: 1522 Colby AVe, EVerelt,WA 98201 <br /> '�' 3.Malling address(If dlfferent): <br /> II � <br /> I q,Resldentlal address at the time oF the Incldent(If different From airrent address): <br /> �� <br /> 5, dalmant's telephone numher: 4?_5 258 4369 425 377 3787 <br /> 6.Clalmant's e•mall address: <br /> riddell3�o�gmail.com ��� 8uslness <br /> INC[DENT INFOqMA7ION: <br /> 7. Date of InddenL ___ aug 29, sepl 5 Ttme: ❑a,m. �p.m. (check one) <br /> � (mm/dd/yyyy) <br /> - �. If the Inddent oaurred over a period of tlme,date of flrst and last oaurrences; <br /> frnm: 08/29I201�m�; C�a.m. 0 p�m.(chede mie) to 9�512013 71me: ❑a.m. 0 p.m.(check one) <br /> (mm/dA�yYVY� (mrcVdd/YYYY) .. <br /> ! Snohomish, WA EvereR <br /> 9.LowUon of IncldenL <br /> ;: StaM and caunry U'!};lfappJlcaWe P/uce�fhae aaurred <br /> 10, If Nie Incldent ocwned on a street or hlghway: <br /> . Ndme oftheet orhighWay At Nre fntr�scdlon rv!(h or ncurcsflnfersecf/ng stmef <br /> � Rov.07100 <br /> /l � <br />