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� ��f��•�UV �.I� <br /> � n" TOR'T CLAIM FORM SEP 2 0 2013 <br /> qev,07(09 mm <br /> Pursuant ro Chapter 4.96 oF the Revlsed Cade of Washington (RCW), 4.Ak i `N'� �V����A <br /> thls form Is for flling a tott clalm against the City of Everett, Sorne oF� �}�, Cl�,k <br /> the InFormatlon requested on thls form Is requlred by RCW 4.9G.07.0 �y _ <br /> and may be suhJect to publlc dlsciosure. The Qry Clerk Is the Gty's CIIyCIoikClnlmNo. <br /> deslgnated ayent for the purpose of recelving clalms. Clalm lorms � f� �' I� <br /> cannotGesubmlKedelectronlcally(viae-mal/or/axJ. ��p�300�/$33 <br /> ... . .....x' . i; \'L '� "@ 4t� a � �i� t P fi� �-� tit � �-a.t <br /> �P,6RAS�,LYP�iO,k�PR�T;CL��RLY;.Y.t��kHf� :���.,:., ::k;:,...>+` .;� ...�1..;\ .,...o,.::�.,.� w�:....�.ni_.�k.�,��.ti.��.:� - <br /> Mail or deliver original slgned clalm form to: Offico of the Clry Clerk <br /> City of Fvorett <br /> 8usiness Hours: 2930 L4otmore Ava.,Stc.1-A <br /> Mon.—Fri.,8 a.m.to 5 p.m.,Paclfic 7imo Everett,WA 98201 <br /> Clased an clry holidays <br /> CLAIMANTINFORMATIONt � <br /> 1.Clalman['s name: ' <br /> - - fo��o�-._.----- ._...._.._ �a1nl��/.4�2_�__ .._.__....__ ._. ._ __�.��.11.�._I�I�S..?. ._ _ <br /> Lasiname Flrsl M/ddle Dafcalb/�th(mm/dd/yyyy) � <br /> 2. Curre�t resldentlal address; �2- � � �-� �� g� ����`J V��a�wI <br /> 3. Malling address(If different): <br /> 4. Residentlal addrrss at the tlme of the Incident(If different from current address): <br /> S. Cialmant'stelephonenumber: yZS�7S2'�87ZS �ZS'�514-��3d�Q �ZS'y`4�c'Gi��o�2 <br /> D'S1u���� [�6�44��0 , CUtril/ a:rslness <br /> G, Clalmant's e-mall address: _ _ <br /> INCIDENTINFORMATION: . <br /> 7.DateoFlnddent: �uC �,�l� h 71me.: ,_? �a.m, Clp.m. (checkone) <br /> �dd1yYW) � ' � - <br /> 0.iF the Indder�t ocaned over a period of tieic,date of first and(ast ocarren[es: <br /> � (rom: Tlme: ❑a.m. l'p.m,(rhedc ane) lo^ 71me:___0 a.m. 0 p.m.(check one) <br /> (mMdd/yyyy) 1 (mrNddJyyyp) <br /> 9.Locatlon of Incident �� r1 �vl��vt�M,�LG k �(�F,YLc�if �-t 0 '�"�'�4- <br /> Sla[c and rounfy dty,!/appl/cvble P/are wheie onvrted <br /> 30.If the Incldent occurred on a street oY hlghway: <br /> Name ols7reetaMghway At fhelnlersectlon wilh ornevms!/n(ersecl/ng sireet <br /> Rev.07f09 <br /> i� <br /> a ��,. <br /> ! <br />