Laserfiche WebLink
Clty ol Evarett Uso Only <br /> TORT CLAIM FORM l�i d..�� Y �U <br /> Rav.07/09 DEC 3 2013 <br /> Pursuant lo Chap6er 9.96 of the Revised Code o( tiVashington (RC1N), <br /> this form Is for filing a tort claim against the CIty oF Everett. Some of ��( dF E�/'�jt�'j"j' <br /> lhe Information mqucsted on this (orm is ieqWred by RGYJ 4.96A20 <br /> and may be sub)ect to pu6lic disclosure. The City Clerk is the Gry's ciiycien�aa � �(�� <br /> des(gnated agent for lhe purpose of recelving claims. dalm forms '�3oO_13 <br /> cannot be submlHed e%ctroniral/y(vJa e-ma!/orfaxJ. ����Oy�' <br /> _ ._ --- —_•—.� .------ <br /> I.���S�`°fYR�O�RIfTT'CLEARL'Y N�K_-_.._�_._�------- ----- - -------�-.—' -_— <br /> Mail ar deliver original sfgned clalm form to: ONice of the City Clerk <br /> City oF Everett <br /> Business Mours: 2930 Wetmore Ave.,SM. 1-A <br /> Mon.-Fri.,8 a.m.to 5 p.m., Pacific Time Everett,WA 98201 <br /> Closeo on dty holidays <br /> CLAIMANTINFORMATION: <br /> 1.Clalmant's name: <br /> _ _ � rti ir 1�� C�l� (7�-l� J- � <br /> lastname tirsi Middle Dateafbl�(mm/dc(�yyyJ <br /> 2:Current resklentWl address: ���(L� � ��� C%r' ��� ��1 /A ��J� <br /> 3. Malling address(If different): <br /> 4.Residentlal address at the Hme of the Incident Qf diHerent from current%.ddress): <br /> --!��cZ-�1( �� !I��t- �'���1/`�,. 4l � /a �� <br /> 5.Claimant's telephone number. 6 0� ' ��'��p �n� - G J� ��oU _ <br /> Home Cell Business <br /> 6.Claimant's e•mail address: _ <br /> INCIDENT IN FORMATION� <br /> 7,Date of incident �r�� �U� > lime: U a.m, ❑p,m. (chedc one) <br /> (mrtVdd/yyyy) <br /> 8.If the incident occurred over a period of tfine, date oF tirst and last acurrences; <br /> from: llme: fl a.m. 0 p.m.(check one) to Time: 0 a.m. O p.m.(chedc one) <br /> (mMdd/yyyy) � (mMdd/yyyy) <br /> 9.Location of Incident: w�C�_���� c��/kX�! ' v' 3�� r f� <br /> STafc and munty O�ty,i/applirvble Aarn wAe� <br /> f0. If lhe (ncident occurted on a slreet or hlqhway: � � �J��lJ � !� <br /> S�1-�—e.e� � C�a�h�,�c.�. �-,-eP d7.e�-c.,�-✓ , <br /> A{�n�eolstrtrfahlghway —�—� Attlrelnfaserfrovrw/fhorneamY/n(rrsectlngsbeet <br /> Rev.07109 <br /> ���� <br />