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R���`Y'�°E� '� <br /> TORT CL,AIM FORM SEP 0 5 2013 <br /> p��.o,�as <br /> CiTY OF EV£P.ETT <br /> Pursuant to Chapter 4.96 of the ReNsed Code of Washington (RCW), <br /> this fortn Is for Tiling a rort dalm against the City of Everelt. Some of Cit�+ Clerk <br /> the informatlon requested on Mis form Is required by RCW 4.9G.020 <br /> and may be suhJect to puWic dlsdosure. The City Cierk is the City's CIryCb�k Cl,acim/�No. <br /> designated agent for Ne purpose of receiving claims. C/alm forms �I{''�� – 1� <br /> cannotbasubm/ttede%ctroniwlly(v/a�mailor/axJ. '"`J � � <br /> R�E71�E"T1�PE'G�tP$�[�ri;�4�A�LY�'.IN,TNI��. �. '.:;:': ;���. ,..�i x.� �.i.� t ":.. �: �,; .�.,,'��` S.�'°, . ,. ., ;1-;:. <br /> �? ,. . <br /> Mail or deliver origlnal signed clafm(orm to: Office of the Clty CIeMc <br /> City of Everett <br /> Buslness Houre: 2930 Wehnore Ave.,Ste.l-A <br /> Mon.—Fri.,8 a.m.W 5 p.m.,Paclflc Time Everelt,WA 98201 <br /> Closed on cily hotidays <br /> CLAIMANT INFORMATION; <br /> 1.Clalman['s name: <br /> �� GrpE,NS , SKG LL l��F�21 � Iq'+� Z, <br /> last name � h7rsf M,'ttidle Oate binh(mrr{/Od/yyyy) <br /> 2.Nrrent resldentlal address: � S I 9 e o t, k3 Y .4�E• E u612E i 1' wh GSzo� <br /> , , <br /> 3.Malling address(�Fdifierent): � h�R <br /> q. Resldential address at the Ume of the Inddent(If dlfferent from current address): <br /> ,Qw.i,,.� <br /> S, Claimant'stelephonenumt>er: _ `Io'ZS-339—`IILZ <br /> �"� "Homc Ccl/ Buslxss <br /> 6. Qalmant's e-mall address: �/,�L4— `}-e �'-�—�'^^ _ <br /> U <br /> INCIDENTINFORMATION: <br /> 7. Da[e of Inriacr.0 0� 2 q ��3 llme: ��'�� ❑a.m. �.m. (diedc one) <br /> (rtvrydJ/ ) <br /> 0. ff thc Incident oaurrecl over a period of Ume, date of first and last awrre�ims; <br /> from: Tlme: ❑a.m, 0 p.m.(check onej lo._ Tlme: ❑a.m. 0 p.m,(check one) <br /> (mmldd)yyyy) (mm/ddlrW'W) <br /> 9. Lawtion of IncidenL• ��i:��ln k W4' � �-lT ��4 ����� <br /> Stale and rounty —' nry,lfapplkable Wam whem aro d <br /> 1D. If the inddent ocmrred on a slreet or hlghway: <br /> "L._ <br /> Name ol5frtrt ah/ghway Af Mc lnMscrtbn w!M arncvrest infenrcUng sfrtrf <br /> Rov.07(09 <br /> / � <br />