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i <br />,' <br /> Snohomish County P.U.D. No. 1 ����UN: <br /> ° Claim for Damages a <br /> 1456 Rw. 9/96 � <br /> �� Yaoro�me(mciode.poa,e,i[m�rtied? Hane phme M Wodc phooe M <br /> Snea�ddmu Ciry Sute od rip tods <br /> ��m�� Dueofinddmt Appmx�re ' AmomtdQ.im <br /> � 7 '�` Ave SE �� /v�rx��r. s <br /> N+ma dPIJD emPbYa+P��C�Imown) Wimeaa.it�y (�me+.�ddmrw.�od pbaoa n�ben) <br /> C at^ie � 'Kc ��rr <br /> � •? <br /> hQase provtde s`6rkEdacription ottfie taciden�,includioQ any defector acdon thaccausedyourdamage= <br /> .. . < . <br /> � � � <br /> � � �' . <br /> i, � ..e.ci'� <br /> l�Pd >�� � VY� <br /> �. � <br /> 2 �. <br /> 3. g, <br /> �. y. <br /> s. io. <br /> � I heve rad the fo�egoina claim,lmaw ita contents,end believe tho same to be true. I catify urder penelty of pery'cry wda the aws of�he <br /> Sute of Wulrin�mn tlut ihe foreQoing ia true and cocrect <br /> e <br /> � <br /> � Data Plere Your signadae Title <br /> Instructions <br /> 1. Please complete this form and retum it to the Risk Management Depaztment,Snohomish County i'.U.D.,P.O.Box <br /> 1107,Evuett,WA 98206. Pleate retum your claim form promptly,as we must receive it to process your ctaim. <br /> � 2. ff}rour claim involves damage to your property,piease obtain at least one repair estimate and forw:rd it with your <br /> �� claim. <br /> °: 3. Upon receiving your ctaim,we will immediately forwazd it to our independent claims adjusting fum. You will be <br /> � contacted direcdy by them within three working days following receipt of your claim. <br /> s <br /> 4. If you have questians regarding your •laim or nced additional information,please call the Risk Management <br /> Deparunent az(,296)258•8395 or toll:i,;e in Washingmn State at 1-800.562-9142,extension 8395. <br /> q25 <br />