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Clly a(Evtlell Uu Only <br /> �������� <br /> TORT CLAIM fORM <br /> OCT 0 3 2013 <br /> Rn.07(09 <br /> Putsuant to Chap[er q.96 of the Revlsed Cale of Washingron (RCW), �IT'1l OF CVER�T'T <br /> thls farm Is For Illing e twt clalm egalnst Ihe Clty of Everett. Some of <br /> the Intarmatlon mquesled on fhls form Is requlred by RCW M1.96.020 Ci�C�N'� <br /> and may he subJed 6o publlc disclosure. The Clly CJerk Is Uie Clty's Llty Cbik Llelm . <br /> desipnated egent for the purpose of reccldn9 cialms. C/n!m/ornrs ��(�� - I'� <br /> canna[besuLm/thdelecfmn/ro/ty(v/ne-mallorfex). _ ���,,�D��& <br /> LXAf1Zp-LV1L�.4S'..l !ilY�ll.I�h�..��5L1F[�LIT��w�u�f.��1'.�i.�.'fiia�'LYI:-�.u15�ll��zu'.n�i�rl._,�_"��z`d.:1Z�t�•'••'.�i.°�L�F.c:1.�°G,�.-� <br /> Mall or dellver original clgned dalm form to: ORico of tho City Clerk <br /> Clty of Evamtt <br /> B116I11666 HOIIY6� 29)0 Wahnore Ave.,Sta.1•A <br /> Man.—�rl.,8 a,m.to 6 p.m.,Padflc Timo E��erett,WA 98201 <br /> Clored on dty holldaya <br /> CLAIMAMINFORMATIQn; � <br /> 1,dalmanPs name: <br /> �ANSo�tc�a'�wd S�pnlv CO. <br /> lest nena flist Mkh'Ic Da1c olWrtl�(mrrydyyyyy) <br /> �•Sf <br /> 2.Current r5sld llal addmss: 3�IY!3 �o�i��N h� �H�,k� I.v f� c�za l <br /> � <br /> 3.Malting address(If dlffcront): $a M.q ____ _ <br /> A.Reslden0al address at the tlme of tho Inddent(IF dlHerent fram arrent addross): <br /> ' N/A <br /> I 5,qalmanCs telephone numbcr, - -, _-- -. y z S- 2 Sy'_9V.C�) <br /> 11ome CMl �ds'lMr.a' <br /> G.Galmant's e-matl addmss: cv�r1•,M i�n�, .1� � fohw��/�.�Sy+.l.ly�p�n <br /> � 1p1CID[NTIN ORMATION: � � <br /> i <br /> i 7. Uate of Incident; . � � (I],__. Time: E""-N•�� CJ e.m. l�p.m. (Utetk one) <br /> (mrNdl/rrvvl <br /> � 6.11 lhe IndAent ac^.urted over a pedal o(lime,data of(Irct and last occurrentes; <br /> � from:, ._ _ 71me:,_ ._...17 a.rn. 0 p.m.(check one) lo,_ 71ma: 0 e.m. �p.m.(check onn) <br /> (mm(Ae/ryryl (mm/dyyyyy) <br /> 9.Wmllotio�lnddenl: _ ��'r{� �W�1� �/� <br /> SMfonrxlmunry �QYy;I/n/y4kaGk PtixcwAur�nmed <br /> � <br /> f0.ff thn IndAeM aamed on a aheet or lilghvny; <br /> -- �� - -- — <br /> . . � —'- -�Nanwdal�lnAy7Mr�V � �IfAehrfenMlanwdAor��eaiecfhfennYAw�sGarl <br /> � flev.01NB . <br /> I <br /> � <br /> � /�h' <br /> � <br />