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� • � � � • � CIty ol EvenM Cu Only I <br /> : RECEI�TE� I <br /> :'.3��RT CLAIM-FORM I <br /> aw.0��09 ,' SEP 2 5 2013 I <br /> Pursuant to Chapter 4.96 af the Rcvlsr�mde or Wufiington (RCW), ��'Y 0F EV�E'�`�' <br /> this Form Is for Flling a tort daim agafistthealyd Li�erelt Same of <br /> tlie InFormatlon requeshed m thLs.form Is reqWr� by RLW 4.96,020 ���� <br /> and may be svbJect fn ppbii�dFsclosvre: The'Qty QeHc'Is the qry's CItyCIoikClelm No. <br /> deslgnated agent far the purpose of recelNng clalms. f/a/m lfvrms � I��. - �� <br /> wnno�besubm/ttedelrrbvn/�aJ/y(dae�wil/orf�J. � 0 300 +/5 <br /> I""' r��� '`r..�. rv! i .t 1 .�1: <br /> PL•EASE,Ty_Ph,��:01���!RI�i�Y:��NK_ `-= ......`_ .�,.. ,.�. . . .. ...t. .. .. .. .... ... ... :(I <br /> Mall or deliver origlnelilOnedU�taren to: Oftice of the City Clerk <br /> City of Everett <br /> 6usineae Houro: 2930 Wetmore Ave.,Ste,l-A <br /> Mon.-Fri.,8,a.m,to S.p�.1�dBc?frme L'veretq WA 98201 <br /> Closed on city holldayn <br /> CLpIMANT INFORMA7IDN: <br /> ].ClalmanPs name: <br /> �R�tN ` ���iZ�� �►',�r i o3� � �� 16� <br /> lest name Hni Mlddle 013fe ofblith(mnydQ/yyyyJ <br /> ' 2.Current resldentlal addne�;L�S b �� 5�t �L. ��� ��{ � W� �g �2.� <br /> 3.Malling address(If dlffererd�:. `�i� 1���{���{�C'� �1V E��l� �� � � <br /> 4.Residentlal addre�at the tlr�of the hfWent(IF dlf(erent from current address): <br /> !4� �� � 1 �RoR>1�P�-r �v�� � — v�r� q82c� l <br /> S,Cialmant'stelephonenumber: �"�-�-�'-"1�-4-�"Z �25� ��I''�� <br /> Home Cell Bus/nrss <br /> 6.Clalmanrs c-mall address: `1�- 'L�AY HPr� '1��A`1N!\ � `��11�0 ,C_C)N1 <br /> INCI�ENT INFORMATION: <br /> 7.Date of Incident �.�.�f I� , 71me : � '-s'.�❑a.m. �G p.m. (check one) <br /> .-.(�*NaNYm1 , <br /> 8. If the Inddent occurredm2r a periad�thne dateof�st and last occurrences: <br /> 6om: Timc •- O a.m.�Dpm(di�cone) to Tlme: ❑a,m. �p.m.(check one) <br /> (mm/dd/yyyy) � (mMdd/yryy) <br /> 9, LocatlonaFlncident; �lu- �FZbA�LJ�'`1 _�€_i( �AS�.�IT� �UE�1i�E �A982o <br /> Sl�Oem�dtmmty pty,/fappflcable PWcawhereoaurred <br /> SO.iF the lnddent occurred m a �or hlghMray: <br /> �'� (:OIU $C�1`J1�`I?.1b�"I SO ��OdUt-=� � <br /> M1ame nfshmt orl�y •AfMe Infrim0'm wMh anmmst lnfersecCitqaherl <br /> Hev.07lOB <br /> ,�� <br />