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i <br /> � ') i <br /> l�t�' ' <br /> � <br /> ��.��.��.�1°��.� , <br /> � �o�rc��ee�;���e+� sci� zs �o,:+ <br /> nc�.w/as <br /> Pursuant lo Chapter 4.96 0(the Revised Code of 4Vashingten (RCVJ), �^������ E�P������ I <br /> lhls form Is for NIn9 a lort clalm a3alnst Ilte fJty of Everelt. Sorne of ��Fn �'��� i <br /> tlie Informatlon reque,ted on this form Is requirzd by RGV:4.9G.020 �r I <br /> " �- -� � antl may be sut,+ed to publlc disdosure. 71ie Ci;y Clerk Is the dty'; c,rycie�rciaimt+,. <br /> deslgnated a9ent for the purpose of reccivin9 clalms. [lalnr /orm� '� l(,��, � I ) <br /> utnna[be subndtted elad�onicalty(Wa e-mail nr�axJ. <br /> - — _ G�C��3ob�f55! — <br /> RiEA5GNF8ORPRYNTCLEARLY�YNIPdk � � . . . . <br /> f�lnll or deliver erlgina�si�ned claim form to; Office of tho City Clerk <br /> Ci:y of Evcrett <br /> Buslnc•,s Hours: 2930 Wetmore Avc.,Stc. 1-h <br /> Man.—Fri.,8 a.m.to 5 p.m.,PacificTime Everett,V1A 98201 <br /> Clns2d on city holldays � <br /> i <br /> i i <br /> CLAiMANTINFQRMA'�QN_: '� � <br /> I <br /> 1.cizlmanCs namc l '� . <br /> �_�-o ��s�ti�---- Cl� zQbr.-.�_ �.ni'i 1�n�_ �_�.�_�-;� j <br /> Lest name + F/rst1 Mlddle Dafe ofhlrth(mm/dd/yyyy) I <br /> z.Nrrent res�dentlal eddress: _�� I� l" � I A V� (=V t'1'P��� �73 ��U� <br /> � 3.hialling address(If d'�fferen[): � — ._ _____ <br /> �1.Residentlal address at the tlme af the inddent Qf dlffcrent fram current address): . <br /> i � �r +_ C� `/�cy-• I, , /irr; � r -: r , pc.. 1, I <br /> . 5.GalmanCstelephonenumben I'Q�..,� ���' q..�p --_3�`1��_�=. �a� �-',�- (� • I <br /> No,v:e LLl! ' Oaslnets <br /> 6.Cialmant's e-ma��ac�dress: _�2e_�_��.�1-�S.SC-1�_� n � ' � C>c�t _ � <br /> 7NCIbENY IN_FOIiMAT10�: <br /> I <br /> . al l�:Aa"J: ao � I <br /> 7.Uate nf b�UdenL• �f�;'/� ����_� � 71me : ___ I�a.nt p.m. (chech ane) <br /> (mm/da/WYV) <br /> n.l!ihe indJent acurred ovrr a pei(ad of time,datr.of flrst and iost nrarrences: <br /> from:_� _—__ nmc:._—���•m. 0 p.nu(da¢k unc) L� Tlme ❑a.m, (]O.m.(chttk one) <br /> (mm/JAhyyy) (mnVdd/V1'fA <br /> �Nn J110� 6 5 �1 rV�"C?"r �71�51? 7�- ' <br /> 9.Lowllon of InddenL /� ; 1 �'�L�' L ��. -- ---1Tltln�-S-. rC1���G'� <br /> 51dlemdmmif O� ^ C7tyl/D(J(1/iWL;�: PI�Le1VACh'GfNf2'll <br /> I <br /> � - d0.If Uio Indden[ocarred on a street or highway: <br /> I <br /> ._---� AS:neclsfrc,lahJhnaY - - —_- At!"rfqlr:_re5':nu';5wnrua7Gr.'erse!7ta9streef —_ <br /> � <br /> � I <br /> �'�%°� � <br /> � . <br />