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��,°���1�� <br /> Ev T�RT CLAIM FORM SEP 2 3 2G13 <br /> Pev.07/09 T <br /> Pursuan[ to Chaptcr<l.96 of the Revised Cotle of Washington (RCW), "���� �����T g <br /> [hls form Is for filing a lort daim against the Qh�of[verett. Some of �,'�ttl �,'��q`�( <br /> Bie In(ormatlon reyues,ed on lhis form Is reqWred by RCVJ 4.96.020 � <br /> and may be subjcct to publlc disdosure. The Clty Clerk Is the Clty's CIIyCIo�kCIalmNo. <br /> deslgnated agent for thc purpose of reczlving dalms. Claim fonns n I�l�j � �r'� <br /> cannof be subnrltted e%cfronirnlly(via e-mall o�f.�x). ��3 p0 Kl'J�J <br /> PLEASE��7YPE�OR.iPRINTCLEARLY�,:ININK��:>, . . , �� . . �. . �. . .. . <br /> Mail or deliver arl9lnal slgned clalm form to: Office of tho City Clerk <br /> City of Everett <br /> Buslness Hours: 2930 Weimore Ave.,Ste.1-A <br /> M11on.—Fri., B a.m. to 5 p.m.,Paci(icTime Everelf,WA 98201 <br /> Closed on city I�olidays <br /> CLAIDIANT INFORhiATION: <br /> 1. Clalmant's name: <br /> _s��j_�'���____ �u�t�., �,�1,��6. � 6 -// - 3 � <br /> [asfnanrc � FinT Middle DafcolGlith(nm�/dU/yyyy) <br /> 2. Current residential address: .�D_'�/ ��r o h e�' J� �e • ��e r e�, �1 r� 9�;�v l- A�/2 3 <br /> 3. Mailing address(If diffcren[): _. _ <br /> 4. ResldenUal address at lhe time of the Inddent(iF di(ir.rent from current address): <br /> 5. ClalmanCs telephone number. 4I:Z5-,75A- /97 5 . __ _ <br /> yonr� Ccl! Qusincs,r <br /> 6. Clalman['s o-mall addres;: . __ -_- <br /> INCID[NTINfORMqT10Nt <br /> n <br /> 7. Dale of Inddent: � �'<� I- �-3 Timc: ?. (�a.m. �+�I p,m. (r.hcck one) <br /> —�---- <br /> (mmlddlyyyy) � <br /> f1. lf lhe Inddent o�curred over a perlod of Ume,dale o(flat and lasl occur,ence;: <br /> fivm:__. _ Tlme:_ .LI a.in. LJ p.m.(chcck one) lo Time:__0 a.m. Ll p.m.(check one) <br /> (min/dd/YYYY) (��nnJ�Id/YYYY) <br /> 9. Locatlon af Inddent: .�,l�I�_S���w�.,�'�. - fJ�'^z`� �os6 ��vo,�er R vz. <br /> 56vfe��ndrounlY [ity,if<�ppllcaG,h Pl.�aa•whemoccunrd <br /> 10. If Ihe Incldent oaurred on a slree[er hlgh�vay; <br /> Namen/slra�lorhl9hway --.. .�—�--�� Atlhcln!e�scdlan�9(horneamsti�denccNrgs(nrt -- <br /> ftev.07/09 <br /> 1 <br /> � � \ %/ <br /> I '���./',.;' <br /> { ii <br /> \ I :.o- <br /> � . <br />