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1 v 11 <br /> _ . .. ._.. . .. __ _ .. . ..__.. . . . . . . . . . . . . <br /> � .TORT CL43M.FORM AUG s o 7ot� <br /> �.��� CITY OF EVERETT <br /> Purwant ro Chapter 4.96 of the Revised Code'of•WasMrgton (RLW), Clty Clerk <br /> this Fnrm is for N[rg a toct clalm against ihe Cily of Everett. Some of <br /> the Informatlon requested on thls farm Is requtred by RGW 4.96.020 Cily Gedc Gaim No. <br /> a�d may be subjed to public disclosure. The C�y CMllc Is Me Gty's <br /> deslgnated a9ent for ihe,W�pose of:receiving daims.: Grim /omu D��ot�- _ +3 <br /> wnrtotbewdunlKedeibchovdra/h':(vla rmsl/orfa�l• - <br /> ..., -..- -: < -, � <br /> o . . . ... _ - -c <br /> � '` ,.,__ �..:: s ' :, <br /> PIEAS_ETYPEOg:FRt�:�__�1�. �_ ,,; ;_�... :� __... _ i <br /> Mall or deliver otiginal slgned daim form to: OfNce of the City Qerk <br /> - � . �- - City of Everett <br /> 8usiness Hours: - �: 2930 Wetmore Ave..Ste.i-A <br /> Mon.—Fd.,8 a.m.to Sµm.,:Badflc iime Everett,WA 98201 <br /> qosed on dty holidays <br /> r�,pIMANT INfORMATlON: � � I, <br /> 1.Qaimant's name: � - � ' � i <br /> —f�„m., t 56FFQfck MtWAEL o4t��A� 1982 � <br /> tastname FLsf Middle Dalco/b/Rh(mrydd/YYYYI � <br /> 2.current residential address: 3Db ALDE2 Sr �eU'G-�e'i T wR 9�2�� i <br /> 3. MaIIMg address(if differen[): <br /> 4. Resldentia{address at the Rime of the Inddent(f different from current address): <br /> 5. qalmanYs telephone numbet: �25-58�-`j39S KZ5�3�`f�z� _ NIS-508-`GN�2 <br /> N/aaw LCII HOME fel4 Buslness <br /> 6. flalman['s rmail address: <br /> INC�ENT INFORMATION: � <br /> z �ate ot�ncident: o`E I 29I Zu�3 ` �me: _G�__ ❑a.m. a(Yp.m. (chedc one) <br /> qmnuaayvrv) <br /> 8. If the inGdent ocarred amr a;perloQof:t�ne,'daM'oFfiSt and last occurcences: <br /> from: nmer . �:. :Uam.�O pm:(chetk one) m Ttme: ❑a.m. O p.m.(d�eck me) <br /> (mm/de/YYVv) , <mn/dd/vYVY) - <br /> 9. Lacadon of Inddent: WA' sa°HD1q`.�1 �ERe1T NuME �.o'�F2 FAh3�K QM AN� '�t�'rv <br /> Sb�.mMmrsrtl' .Citl:lfappNcable � Vlaawhereo¢unrd � <br /> 10.If the incident oaurred on�a street or M9hi^raY: <br /> Nmx ofstree�t ahklhMeY At Me/Masectlan wA'h ormvrestlnfenrcfimJs(reet <br /> pov.07108 <br /> /2 <br />