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Claim for Damages Form

  1. This Form Submits Directly to the City Clerk.

  2. CLAIMANT INFORMATION

  3. Current Residential Address

  4. Mailing Address if Different

  5. Residential Address AT TIME OF INCIDENT (if different from current address).

  6. INCIDENT INFORMATION

  7. Time*

  8. If the Incident Occurred Over a Period of Time, Date of First and Last Occurrences

  9. Please Include a Brief Description as to the Nature and Extent of Each Person's Knowledge.

  10. Please Attach Any Other Documentation That You Believe Supports your Claim.

  11. ADDITIONAL INFORMATION REQUIRED FOR AUTOMOBILE CLAIMS

  12. I Declare Under Penalty of Perjury Under the Laws of the State of Washington the Foregoing is True and Correct. This Claim Form Must Be Signed by the Claimant, a person Holding a Written Power of Attorney from the Claimant, by an Attorney Admitted to Practice in Washing State on the Claimant's Behalf, or by a Court-Approved Guardian, or Guardian Ad Litem on Behalf of the Claimant.

  13. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  14. Leave This Blank:

  15. This field is not part of the form submission.