3515 WETMORE AVE 2016-05-27 - Laserfiche WebLink

t ) RECCPETV "1110161!"t A J TORT CLAIM FORM tom 2 3 201,E Rev.07/09 OF EVERETT Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW),this form is for filing a tort claim against the City of Everett. Some of City Clerk the information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure. The City Clerk is the City's city Clerk Claim No. designated agent for the purpose of receiving claims. Claim forms I cc, 13 cannot be submitted electronically(via a-mall or fax). t3oo4/4t5 PLEASE TYPE OR PRINT CLEARLY IN INK Mall or deliver original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste. 1-A Mon.—Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 Closed on city holidays CLAIMANT INFORMATION: 1.Claimant's name: l)e#hY0l/w AveywL- - CO Ado'MiMM)Uvv,s Last name First Middle Date of birth(mm/dd/yyyy) 2.Current residential address: :S5 15 L)& Pi'i 0 re ,V't. , e'mai, W/\ '111.6 i 3.Mailing address(if different): ?5 i 5 Avg- U if F e vatf(, W AA. q`6-2 D i 4. Residential address at the time of the Incident(If different from current address): o akvi, /,ins CUrra'i!- l,#cjc Y(`S 01400.4 ) 5.Claimant's telephone number: 6 O'1- of o4-JAI$1 �{2S- 33N- (ov t 1 i,4-it Home. Cell Business 6.Claimant's e-mail address: Mi{Iio iWipitl-pv Dt h.iVV1 VAf. EAW) INCIDENT INFORMATION: 7. Date of incident: (5 7J1 iOl 3 Time :42p g- (o ❑a.m.Op.m. (check one) mm/dd/yyyy) 8.If the Incident occurred over a period of time,date of first and last occurrences: from: Time: ❑a.m. ❑p.m.(check one) to Time: ❑a.m. ❑p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) 9.Location of Incident: (AA Sftl.'f t, S(4O f401Mi.s I CO. .e kitirt ,4- .- 3571(n)e4priort-Are tM tS A,13,(r i) State and county Qfy,if applicable Place where occurred 10.If the incident occurred on a street or highway: 35 Iry Avg tothm t Aye Name of street or highway At the Intersection with or nearest Intersecting street