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-- -- - - -- _ _- -- _ . <br /> - - � <br /> (����, I��G � <br /> I ��� � �.��7 � �p ',y�ol ,v r¢ItUseOn�l ' <br /> I � .Il����� V �'I.R.� � <br /> ' � �����'Q/�d�9���/� � <br /> �Cl� 2.n 2019 , <br /> ; n�v.o�/da ' <br /> ! Pursuant to Chaptcr q.96 of the Revised Cdde of YJashing[on (RCVJ), ����/ �������"�� � <br /> , thls(orm Is for Illing a tort clalm a9alnst Uie City o`werett. Some of �j���[�.a•� . <br /> i tlie infoima[ion requesled on thls form Is req�:imd by RCW 4.96.D2D <br /> i and may uc subjecl to puhllc disclosum. The City Clerk Is the City's CIIyCIerkClolmNo. � <br /> P desi9wted ogen[ for the piirpose of recciving clalins. Claim fams ��— <br /> � wnnot Ge suGml[ted electrarlcally(Wa e-nral/nr fax). � <br /> Cqe�Di3oo�l�an <br /> , PLEA§E TYPE OR PFiINT CLEARLY IN INIC <br /> � Mail ur deliver r.ilginal signed claim torm to: Offlce of the CIty Clerlc i <br /> , Clty of Everett �. <br /> . 6usiness Hours: 2930 Wetmoro Ava.,Ste.1-A � <br /> . Mon.-Fli.,8 a.m.to 5 p.m.,PadficT(me Everett,WA 98201 �, <br /> �. Close�on eity holidays �. <br /> j CLIIIP7�NTINFORMATION: � <br /> i <br /> 1.dalmanYs name: � <br /> � NAM ►_�pl._. — Mar�P _ Fra��c� a-s - �F,G <br /> � Lastnamc 1 Fnf hLdele DUMofMrth(mm/dd/�SY) <br /> � 2.Currenl residenlial addmss: ��S �'f �j I C�-�� �C.� C���-LI7—�a' ���/ <br /> �� 3.t•failing addiess(�f di(firent): _ .__ <br /> i i <br /> �I� 4.Residential address al lhe Wne of the incident(if dil(eienl from cuuent address); <br /> ' —����--�1c�1�p�ce.—E��r�!– i�i�- 9 8�o / <br /> ;I � <br /> 5.Cialman['s telephone number. ���l�5�� � �����'✓� __ <br /> i�� H me /� L'ell � /— Budness ' <br /> G.Clalmant'se-rr,alladdress: . �7_L�/]]_t��� �_SQJll_CGI,.S�� — <br /> � <br /> - }NC[DENTINFOjtMqLION: . <br /> ' 7.Dale of Uicidenh �(7\�Z 1_I��j____ Time: _'1_-7 V M_ U a,m.�.m. (check une) i <br /> : I (mm�iWh'117') . <br /> ' O.lf lhe Incident ocarred over a period c�Ume,dale of flrst and las[oaurrenns: � <br /> �! from; Tlme:___U a.m. I7 p.m.(chrlh one) lo Tlme:__0 adn. 0 p.m.(check one) <br /> �� (m�Vdd/YVW) � � � Unm�d:l/YYlY) <br /> ,' 9.Lo�aUon of inddenL• �Q_.�.l��i�i a� �_r�+�e-�-- �Uer - o. �a-o J � <br /> 57ate and munly � Ory,IfappliraG�e P,acc rv,5cm drcumd . <br /> �i 30.If the InddenC ocaned on a strcet or hlghway: ' <br /> /Jime arSfmC!ofle:Oh�vJy Af Ihc/qfC/SEi7iN1 M11I!N JMd�T.HiMYCRLYIy SfrtCl �. <br /> , /� <br /> f/ � <br /> � <br /> � <br /> 1' �It <br />