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-= EVERETT-= WASHINGTON <br />City of Everett <br />Police and Fire Pension Boards <br />Request to the Board <br />To be completed by LEOFF 1 member (or family) for submittal to the board. <br />Member Name <br />(please print) <br />Return to: <br />1.Diagnosis:\� xx:,,,\ \\�, ,c, <br />2.Prognosis: C'.M1 )� lo 'MQ<e, Y'V\C,n¾ <br />3.T yp e of Treatment(s) or Procedure: � \r,.,<Y\YP c O(''\)\'I ooce o &:,,, <br />4. Cost of treatments/service: $ __S>_ _?J-=� .... 5 .... ,_w_B _Paid <br />5.Request to the board for this specific treatment or procedure: <br />� .:::=!'i�;�� .�-- <br />i����= <br />i. <br />Gn l ,\ ,s Ci,\ CM,rmec} t .. ,,"'-, D, \l'u:o°) o,�oc,s\.,c :\:es\­rneA,co \ ntcer.r, 1 hJ (Examples can be found at everettwa.gov/pensionboards) <br />City of Everett Police and Fire Pension Boards 2930 Wetmore Ave, Ste 1-A Everett, WA 98201 Leoff l@eve rettwa .gov <br />$215.68 owing