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. � R����1°�D <br /> TORT CLAIM I�ORM SEP z o 7.ut3 <br /> a�..0�,09 , � CITY OF EVEI�ETT <br /> Purcuant [o Chap[er 4.96 of the ReNsed Code oF Washingron (RCVJ), • CjFv c���„ . . ' <br /> this form is(or flling a tort dalm agalnst the Gly of Everett. Some of �� <br /> the Informatlon requesled on thls fwm is requlred by RGW 4.96.020 <br /> and may be su6Jec[to public discbsure. The City Gerk Is the Gty's ciry aark ae:m No. <br /> designated agent for the purpose of recefving clalms. Clalm fbrms �I� - �'�j <br /> cannofbesubmlttede/edron/cal/y(v/aa-ma!lorlaxJ. �C��.�� �3� <br /> PLEASE;i1fPE�OR PRINT:CLEARLY'_IN:INK <br /> Mall or deliver original siened clalm form to: OHice of the City Clerk <br /> City af Everett <br /> Business Huurs: 2930 Wetmore Ave.,Ste.l-A <br /> Man.-FrI.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 <br /> Closed on city holldays <br /> CLAiMANT INFORMATION: <br /> 1.ClaimanPs name: <br /> STocic.i.vG . �a6rr✓ . Scor-T p6�si961 <br /> [astnamo �;. . , . • ��n , Af/dd/e oureo/blrtn(m,yedh�Y) <br /> z.Currentresldentlaladdress: ��S`I CO�13Y it-✓d„/u� , ��'�� �A 98zoi <br /> 3.Malling address Qf different); S�/�+'+L <br /> 9.Resldentlal address at ihe time oF the Inddent(If diffcrent from cvrren[address): <br /> S'/1�1L• _ <br /> 5.Clalman['s telephone num6er. ����Z-3� '�'308'�� `��`ui�� <br /> Nn/nc CeU Bus/ness <br /> G.Clalmanl's e-mall address: ' o ClG�n �� . o�n v ••• ^.---��^'-�--s-�rlrt'T <br /> NCx IDENT INFORMATION: <br /> 7.Date of Indden[: �� Z LD� Time: 6��U ❑a.m. �p.m. (check one) <br /> � (m n/dd/yyyY) <br /> 8.If the incide t o curred over a pedod of tlme,date o(fi�st and last o rt nces: <br /> fram: OS Zf la/j Tlme: �G 0� 0 a,m. E9 p.m.(check onej lo��� ��s Time:�1'�� dfa.m. I]p.m.(check one) <br /> (mnVdd ) ( M a)yyyy) <br /> 9.Locatlon of Incldent: �✓� .�NO�tlM/S/� G v��/ l S�I COLf3Y .W/-' <br /> Stafeandmunty Qfy,l/appllrab/e P/accivhercocruncd <br /> 10.If lhe Inddent oaurred on a slreet or hlghway: <br /> Name o/sfmrf or h/ghnv�/� At fhe INrnnctlnn��dfh orneamsl lnhrnr8ng sheN <br /> ftev.07109 <br /> ��� <br />