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,- - - -- ---- __ _ _ _ _— <br /> ; - <br /> �t ol E �� "� 1 <br /> ' ev TORT CLAIM FORM SEP 18 2D13 <br /> : °�"."'�°' C�'&'Y 0�EVBRE�'T' <br /> Pursuant to tliapter 4,96 of the ReNs2d'Oude of Washing[on (RCW), City Cley'P� <br /> thls form Is for Bling a rort dalm agalnst the Qty of Everett. Soma of <br /> : the InFamallon requesled on thls fam Is reQulred 6y RCW 4.96.020 � <br /> '. and may bc su6}ect-In publlc dlsdoare: 7he Ory Qerk Is the Gtys CIry CJorN GaLi1 No. <br /> j� deslgwted �geM for the pu�po�e of re�Mng �Ims. delin�oirrts � ��(o�13 <br /> icennatbesubmlttade%Wnlcelly(v/ae•mal/orfaxJ, p�fSl� <br /> f.�iPI,WF1�eJ.P�i�.QRT�11����N1� �•i: RP�_a..tlt. lx :.w.. � M1V�I '. ��•�, J: .t(ie�:F � . . �.�.^P�. . <br /> � 1i�;, <br /> Mall or dellver otiflb�alatgned elnlm fotm to: Offica of the Clty Cleiic <br /> City oP Everett <br /> Buslness Houre: 2930 Wetmoro Ave,,Ste.i-A <br /> Mon.—Frl.,8 a.�l0 6 p.m.,Pedflc Timo Everett,WA 98201 <br /> Cloced on dty ha8daye <br /> CLAiMANT INFOMLIIYfONt ' <br /> i.qalmant's namc <br /> �I Mn��nhaln p»ttif{�+ p711�( _ <br /> �� (astnnme fhst - —-M/Adle OataofGhth(nrnVdtj,y�y) <br /> ; 2,(.ltrrentfesldentlY'addres: 3732 Droadway Everett, WA 98201 <br /> � 3.Maliing address(Ifdfferent): <br /> i'' � <br /> 4.Resldential addr6s n[lhe tlme oF the InrJdent(If dlNercnt fivm current nddress): ! <br /> �I . <br /> �� � <br /> S,Qelmant'stelephorrenumbcr _ 425-263-3523 <br /> Nome 411 BusNess . <br /> G,qalmant'Se-Ii1�Ileddfct9: �aynard�mountainnacificbank.cum ' <br /> 1�V IDENTINFORMATION: � , <br /> I7.Da[e of IncldenC. Time: ❑a.m. �p.m. (rheck ono) � <br /> . .(mmfdNYY1Y) . ' <br /> '�� 8.lf lhc Inddent aaostr�a�er,a peJbd of th�fC dale of Orst and last aaurtences; � <br /> �'f fmm; oe/sv/ao13�.The: 5:30 ��❑am.��pm(rhodcone) looe/a�/zoi� Time: 7 :00 Oa,m. �p.m,(dicckoncl . <br /> �'.3 (mMdd/yyyr) GmNdd/YYri) � . <br /> � 9.LacaUonoilnddent"waehington, Suohomieh, 8verett, 3732 BroadwaY _ � <br /> . . . .STatr�attdcmdy O'ty,4epP1lwCJe F,acewhemottvnc+d . <br /> 10.1f the InddenC�at a shreeS ro hlghwdy: <br /> • Nameo/�dol�lmey Atl/wMfersrNlaniWfhorncarcstln!erscclggslmct .� <br /> Rov.07108 <br /> r � `! <br /> ���i <br /> l ��- . <br /> ��' <br />