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r�/� <br />'A�� <br />770RT CLAIM I�ORM <br />�a.e�lo� <br />aunuene �o a� �.� o� cne Rews�d coae a wa� (rtcw), <br />thls form is for fAlo9 a tat dahn egahnt the CHy W Everett. Same of <br />the Informadon reques�ed on NNs fam Is requkcd by RGW 1.96.020 <br />and Pnay be subjed to puWlc dhcbsurc. The qry Ckrk Is the Gty's <br />dWgneted agmt for thn pupose of rcceNing cJakns. Qahn !b►nrs <br />cannotbeanbmiMadek'adwdallp(Wi s-mN/or/ur). <br />�11�Ed�YRR'=!�'�G�I�L'Y�IN� ��' <br />MNII or daliwr odyi�wl dpned ciafm Iorm to: <br />9uNnan Noan: <br />Men. — Rf., ! am. to 6 p.m., PaciOc Tlme <br />Closall on dtY hoNd�yi <br />h__ �... ,� i,.:�.. . . � �:, <br />NOV 2 0 2013 <br />ClTY OF �VF,,�L�"T <br />iYlq �la�k <br />oma orcns ctcy cvadc <br />Cky M Everal! <br />2930 Wabnow Ava., Ste. l-A <br />Ewr�ly WA lS201 <br />1. Catmanl's name: <br />/�/ea✓ �•�.�.� 1�vc.�,P .ti, r--� Ca..,yo.n.,..e� G Z.L <br />. . c�� u�ld� - II.�.NAMA/w.w <br />6 .�ircE <br />2. Qxrent wYsdNLaddress: <br />3.�i�,9ma�crairr�r�: s.�.-.-,� �vsr-�+� G✓� r—/�G/ <br />�.a.,.i s� <br />�.AaeidenNsl address at the tlme of the Nidde�t iif diRereM hom arteM addrcss): <br />Z ti G'� ��.,, ff Z �'i // f/eu. �ff .o :�- .G Z �'i /5 /�.,.. � <br />'/ �L ���.✓. {Y Sc. . -�t "'� / <br />5. dalmant's telephone �umber: <br />6. CWmaM's e•maA address: <br />i, «�..a.i i, .� � � . <br />� <br />7. oete of Inddent i Z�''� Zr./3 <br />lmnJda/YYn) <br />�il�-z�.>,z�s <br />L�lY Bimi�ea <br />�rFMW...�r�Nt�t[/. G�M • <br />Tlme : lo: � ❑ a.m, ,{�.p.m. (checic one) <br />8. If lhe Incklent occwred over a perlod of tlme, date of Nst ard Imt aaurrcnaes: <br />from: Time: d:� 0 a.m. O pm. (d�edc ros) to 6:00 = Tkne: 0 a.m. f�m. (dmdc a+e) <br />(mmrJdelyypVJ' (�Vd4�YVW) <br />9, �«auon a �ncaenr. 3'�G •/„0,.,.� /�.•a �ra�_,.a � 2�!e �, z 5 �� � z'� �s <br />A4te�ndcaMb' �Y.�`+'PD�'�+bt A'acexAaroanaind �je•+. <br />10. It the Mddent oavmed on a street or highway: <br />�� <br />