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G ot Ewretl Use Only <br /> ' R�CEI�IE <br /> n TORT CLAIM FORM <br /> SEP z 3 zm� <br /> �.�.�,� <br /> Pursuant to Cliapter 4.96 af the Revlsed Cade af Washingtan(RCW), CYTY OF EVEp�p� <br /> Ihis farm Is for filing a tod dalm aga�nst ihe City of Everett. Some of <br /> Ihe Informatlon requesled on thls form Is requhed by RGW 4.96.0)0 �1C.(-'e,�� <br /> and may he sub)ecl tn puhlic disclosurc. The Qty Cierk L Ihe Clty's ciyaanccie�mtid. <br /> deslgnaled agent for lhe puryose ot rccelving clalms, pe/m Iomrs 1 ��p - �3 <br /> cannot be submltted e/ectron/v//y(vie e-mef!or fer). D �,� <br /> �_PLEAS�TYPEUR_PIUNT_CLEARLY`IBI.INK �� ` `�:.-� . .� .. . ��!' ..i .' _. . . . _ : <br /> Mall or dellver oripina�slgned c101m fotm to: OHite of th�City Uerk <br /> Gty.of Everntt <br /> Buslness Houre: 28�0 Watmore Ave.,Ste,1-A <br /> Mon.—Fri.,e a.m.to 6 p.m.,Pacific Tlme Everctt,WA 88201 <br /> Closed on cl[y holidays <br /> ClAIM6NTINFORMATION: <br /> 1. Clalmant'a name: <br /> ��wa�d c��.Y �s N 6/0 ��f�s�- <br /> Lasf name Hat M/Od'e Dafe o! ' (m dyyy�yJ <br /> 2.Curten[resld�7dlaladdmss: _.�SO6 �'y� ___ <br /> J. MaIIInB address(If dlffcrent): <br /> 4. Resldential address al Ihe timc of thc Inddent pf dlfferent hoin cvnent addren): <br /> / So� Cm�6y _— — <br /> S.Clalmant'slelephonenumber: yu'�S�-�3IL NZS 3S�f—JQQ� — <br /> Nomc Cd/ 6uAnrss <br /> 6.Qaimant's rman addrrss: G N N'DCJ 'A R D y►�, �'roH'}'i Cw . �7 lM _ <br /> INCIDENT INFORMATION: <br /> 7. Date of IncldenL• �S � U nme: � � ? �.m. Q p.m. (check one) <br /> (mm! YYYY) �U Y i hr1I - �d-I V� <br /> 8. If the Incident ocwned over a perlod of�me,da[e of flrst and las[occu�Yences: <br /> hom:0�2t�oj�; ��Uam. �Y{�.m.(cluckone) IQB�ie_ya_t371mc�j{�'a.m, Ilp.m.(chakone)? <br /> (mm/dJ ) (m /YVYY) / <br /> 9. Lowllonoflp��dail:������f('-V�__ _l�v� �1��-/ . <br /> (^l�y'►(/v unty Qry,/lepp7icabk Gla�e whxe ocnmed � <br /> ]0.If Ihe Incldent ocarred an a street or hlghway: <br /> -- ------ - - - ------ ---- - -- ---- -- --------.. _ .__.._---- <br /> Namt dshc�e!oi Ngh�vay A1(Aclntriration idtlr arnmirs!Nhrsnrtirq abrd <br /> Hev.OAW <br /> �lz - <br />