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� �.����D <br /> �v TORT CLAIM FORM SEP z a 2at3 <br /> Rev.07/09 <br /> Pursuant to Chaptcr 4.96 oF lhe Revlsed Code of Washingron (RCW), ��TY OF EVEY�ETT <br /> this Form Is for BIIn9 a tort dalm agalnst thc Gty oF Everelt. Some eF �ity�I�rk <br /> thc Informallon reques[ed on thls(orm Is mqulttsl by RCW 4.9G.020 <br /> and may be subJect to publlc Alsclosure. The qly derk Is the. City,s CIly�ladClalmNo. <br /> deslgnated agent(or dte purpose of receiving dalms. C/aim forms � - ' � <br /> cannofGesubmlttede%ctronlcal/y(vlae-mailorfax), (zC�01300t-(s <br /> i!LEASETYPE'ORVRINi'CCFARLY;II�.INK: . ' ` � . <br /> Mafl or dellver original slgned clalm form to: Otfice aF the City Clerlt <br /> � City of Everett � <br /> Business Hours: 2�J30 Wetmare Ave,5[e,i-A <br /> Mon.—Fti.,8 a.m,to 5 p.m., PaciFic Timo Everett,WA 98201 <br /> Clased on eity hoiidays <br /> CLAIMANTINFORMATION: � <br /> 1.Qalmant's name: <br /> ��Q�-1 e,S �o:� i�e e� o -Lo �'�- �t_�l_g <br /> Las[name � h7iY M.i1A/c LUMo/b/Nh(mrydd/yyyy) <br /> 2.Cunent residenllal address: 1 :J V p �Cl L[.l Y i��G'_���_10L(�' G g��-�� <br /> 3, Malting addrcss ptdif(cront): SQYV1� ay abfl\f P. <br /> 4, Resldentlal address at thc time of lhe Incldent(IF different from current address): <br /> SGvv�e aS�hn�P __— <br /> 5.Clalmant's tclephonc num�er: �'�_'�Q��OSa N� ���OL'��'- <br /> Nnnrr CL�R � Buslncss <br /> G.Claimant's rmall address: _dL7 P.-rnc�.1L�d.d.Y_e�s <br /> INCIDEN7INFONMATION: <br /> 7. Date of incident; ��Q � �-� �3 iime: �'C�U I�a.m. �p,m. (check ene) <br /> , (mm/dd/ynry) �"O� i 0 U <br /> e. If the Inddent oocurrecl over a perlod o(tlme,dale of tirst:md lasl omurence�: <br /> (rom:_ Tlme:__U a.m. fl p.m.(chede one) to___Tlme: ❑a.m. 1]p.m.(dreck one) <br /> (�+l�Jrrrv) (mMddlrvrv) <br /> � "�"' ' I_ � �,, � .�}, � �+-1 <br /> 9.Locatlon of Inddent: y�IJ„b�1.YJ_CJtQt1�_�Y��'.lO�_3�eSe�1 i�-(���� ' V�' , <br /> � StaR�nArounry Gty,!(applka6 M�m wherc ar.vm'd <br /> 10.If the Incident oaurred on a s[rect or hlghway: . <br /> N{t NA <br /> � NamrolshcelMAighway Al(he/nhvsr�fkt�wNh[vnearrst/nMrsrdingsfm'! <br /> Rov.07109 <br /> /� I <br /> �� � <br /> � <br />