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CLAIMI FOR DAMAGES ��t,AA� <br />r�, �; �4�� �� CITY OF EVERETT �5 <br />p 15 . Office of the City Clerk pEC 13 <br />�� ,�,,,� 3002 Wetmore Avenue , <br />. . "' Everelt, WA 98201 !�{fy h�„�.������„ ��„4`: <br />. oi; L�L�iLTT 4a-� $ �o 0 <br />CITY ��,I���C Number (assigned by City Clerk): � l5`T 9� <br />Pe•rson makina claim: Please complete the claim form, attach any bil�s, 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 Cleric at address noted above. <br />Name: <br />Address: <br />� <br />Home Phone No :,,�a-S —337- 3b35 Work Phone No.: '—' <br />Previous address if you have lived at your current address for six months or less: <br />� <br />c <br />Amount of /� e, Date and Time n <br />Damages Claimed: $ a, 6�5 ,��. '` of Incident: �83 -" ��4 � f �94 7��oe �Y • <br />.���Q�ee � <br />Location of Incident: Q.�c,,.¢. 2�J <br />'`�,', <br />��s�r-�. <br />(If you nee`d more �pac�, you may attach another sheet of paper. Please include the names, <br />addresses, and phone numbers of any witnesses to the incident. You will want to describe how lhe <br />incident occurced, what was damaged, who was involved in lhe incident, and lhe extent of any <br />damage. ) <br />(CONTINUE ON BACK OF THIS FORM) <br />