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� Clly ol F.v0�o11 U:u Unly <br /> _.... . . JLA���1 C �� . <br /> err TO/�T CLAIM fORM SEP 1 � 1013 <br /> ���.o�ia� 1fT <br /> Pursuan[to Chapter R.9G of lhe Revised Code nf VJashington (AGtV), C1l i� �� �S���E�7� <br /> Ihls farm Is for Oling a lott dalm ac�alnst Ihe Cily of EveretL Somc of Ci r��,k . <br /> the Informauon requestr.d on lhls form Is required by ItCW •1.9G.020 c�ivci�� „�,,, �o. <br /> and inay be subjr.ct to puhlic Jisclosure. 'Iho City Clerk Is the C+ty's �-� I �!\ ,. �� <br /> deslyna[cd agenl (or Ihr purpose o(rccetving clalms. Llolm forms L� V <br /> casnnLGosuhmiftedelectrarir.nlly(viae_mailurfTx). _ _��pl�OQyS��1. <br /> ........ ......�..... .�-.�. ........ ,. � f � - �1�j � �i4�r�t-i +t�v�.���>�{i^� M �t ili 1 ���S�P!',;.�rNSv�.J_'�'t�Sj:sl <br /> �ei_egsgt'r�;�:h�9R.!eL�EN7sC�ElIRUvFr���tNt<�.i ,., .,,<„ . ..�,�a�,��. . . �e <,,,. ��,..�,�..5i. , , � �� �,... . <br /> Mail or deliver original si�ned clalm form to: ��fty�f Evere��ty C1edc <br /> Business Hnurs: 2930 Welmore Ave.,Ste.1-A <br /> Mon.-��'i.,8 a.m.to 5 p,m.,PaciGc 71mo [verett,WA 98201 <br /> Closed on city holidays <br /> CLAIMANT 7NPORM17ATI0[J_: <br /> � 1, ClalmanYs name: /� <br /> ��}���(l �(/ ��� � - --�-�5�(��' ! L v�Z <br /> '`��—��� '--�'���Y�� ,�;.;1dlc Datc olbfrlh(mn�/dd/}yyy) <br /> � �laAna.wo � f/rst I <br /> 2.Cwrenlicsldentlaladdres,: _�'LLL��(,(f-������J��'"��/_ ��— <br /> 3. �tallln� address(If different): '���.�������i^�-�'-'�`-+-r—"����` _- <br /> •1. Resldr.nlial addmss at lhc tlri�of lhe inddent(If dilferent from cuuenl address): <br /> _L�11_�u.c,Lc���—��e�-1��,t�"�f`��=(11/�--���- --- <br /> ) � �l <br /> 5.Gaimanl's lelcphonc iwmbei: �ZJ'.�2T�-���� �(� _��—`=�>U"— Buslness <br /> .('�/ ,.f /�1y'��{�c �(/� ��}7 C��!•1flr <br /> 6.ClaimanCs e•tnall adtl�ess: JI_v�L�LU��("C�e-�y�/�--u���-.C({-f�---- �---- <br /> INC[DC•NT 7NFOF{MA710N: <br /> 7. Datc of Incldr.nL• �_}�����-- 1'7I1'mc: _I_'�V�)!�� �/�.��.���. P.���. (chetk�or.) <br /> (nun/dAhYrv) ��jC�Lt7'l0� �CJ�/ �?C2A�Lf(�(' '��ClU�lfl-• 1VI"""'-:/LI--� <br /> 0. If tlie Inrldenl occuued over a period of tlme, date o((lisl<md la,l occuirences: U <br /> from;�- U a.m. IJ >m. (d eck oi J°---.J.¶����:---Cl a.m. [1 i>.m.(u�ec�:one) <br /> 71me:___ �� /(;� (inm/Jd/»1N <br /> (mnUd.1/Vl1N) \U C p� /i�"-71�� � j <br /> �Q�,,� ���' �11�Lq�11�{� ��1��` <br /> 9.�ocation of mcWent: _I�LL��•�.���-1-1=��U`��p1��aG'e �� � Place�ti�he�,om�ueA �� (�+ <br /> sretcandrm�nty Y I <br /> LO. �f Ihc Inddr�.n oauri ed on a strcel or hlpht���_ <br /> f� 1� f,U�-«G+( ��. • -_�'�✓C��' � 1,1/l�` ��/2�� <br /> h'aum olshcef orhlghivay At Ihc in(nsr[tinn ir;[h cr nran•et lntcsrc(lnpsUcet <br /> Hov.07l07 <br /> t <br />