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CLAIM FOR DAMAGES FORM <br />CITY OF EVERETT <br />Office of the City Cferic <br />2930 lNetmore Avenue <br />Everett, WA 98201 <br />(425} 257-86f 0 <br />City Claim Number (assigned by City Cierk): �l2 �—� g <br />Person maki� claim: Please complete the claim form, attach any bills, estimates, or records <br />related to the incident for which you are making the claim. Have the completed form notarized. <br />Submit the completed, notarized claim form to the Everett City Clerk at address noted above. <br />Name: S'r� �-n,.i /.lv, _ c+ <br />Address: l-� � %�iiiDRoNA �iV�, <br />Home Phone No.: ��ds� 3 0 3_ 9� 7� � phoeNo.: �sa 9) 6G 3-' .2.20 .S— <br />Previous address if you hapve lived at your current address for s�'�( months or less: <br />�.G/RO-.L�iiAi�nwol� mi.J :�. L/ oo i� _ i . J- ... . ." ' <br />Amount of <br />Damages Claimed: <br />Location of Incident: <br />�` Date and Time <br />$��`� 97� . 6� of Incident: G- 9� ,�.t„ 3 p9 <br />�� <br />Description of Incident: <br />(If you need more space, you may attach another sheet of paper. Please include the names, <br />addresses, and phone numbers of any witnesses to the incident.y You wi11 want to describe hojv the <br />dincident occurred, what was damaged, who was involved in the incident, and• the extent o� any <br />amage.) - .. . :, .z . , •„�.. <br />.. ., .... .�.- • •�.• ,s.„, . .� <br />(CONTINUE ON BACK OF THIS FORM) <br /><<d <br />