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� Ciry ol Evenit Us�Only <br /> � ��C�I�1E� <br /> � TOKT CLAIM FORM gEp 1 9 2013 <br /> Hev.07/09 <br /> Pursuant to Chapter 4,96 oF the Revlsud Code of Washington (RCW), e��'Y OP EVEI�E'�'T <br /> thL(orm L for filing a[oit clalm agalnst the City ot Everett. Some oF C�}� CIC1�.�C <br /> the hiForma[lon 2que,[ed on this form is requlred by RCW 4.96.020 <br />' and may be sub)ect to public disdosura The City Clerk Is the Ciry's CilyCleikCln IN� O �� <br /> designated agenl for lhe purpose oF rece(v(ng claims. Clafm forms �� � J <br /> cannatbesubmittede%ctivnicalty(vlae-maf/orfaxJ._ �,���a0��saa <br /> �PLEASETYPE;OR_PRINiCLEARLY,IN,INK.. . :��:; • :•� :�-�' ,. .�.�-� _....;�::-'� ..'�.:, , . ��.:;;.:';`�l <br /> Mail or deliver original signed claim fotm to: Office of the City Clerk <br /> City of Everett <br /> Bustnoss Hours: 2930 Wetmore Ave.,Ste.1-A <br /> Mon.—Fri.,B a�m.to 5 p.m„Pa�lfic Time Everett,WA 98201 <br /> Closed an city holidays <br /> CLAIMANT INFORMA7ION: I <br /> 1,Claimant's name: <br /> `� ��� ��-�.4�� ��. �g1�Qti� <br /> [astname lrst �1iddle Da ofb/iih(mnr/dd/yyyyJ <br /> 2.Current resldentlal address: �S2 D CiO (�V �U� <br /> _7 <br /> 3, Malling address(if different): __ <br /> 4.Resfdential address at the dme oF thc Incldent QF dlfferent from arrent address): <br /> 5.Clalmant's telephone number. ��� y� � s�'��'' <br /> � f/ome ' Ccll Uusiness <br /> G.ClalmanPs e-maii address: , __�_____ <br /> INCIDENTINFORMATION: <br /> 7.Date of Inclden[: .L���- -�'`S .�` ��ime: �rzc {LrS� I'la.m. ❑ p.m. (check one) <br /> (mm/dd/yyyy) <br /> (3. If the Inclde t'oc�c]urred over a perlod n(Ume,dale of flist and last ocaurences: <br /> Gom:_���'��� Time: f�m. 0 p.m.(check one) to �' Z Tlme; l�a.�0 p.m.(dmck one) <br /> (mm/dd/ypy) (mnUdd/yy�yy).//� <br /> 9.Locallon of InddenL- /<��� l�V��._ �'� �- �-U �'Ul �J� �f, ��nG � <br /> Sfate and munQ� �(y,ifapp!lcab/e M.xe where ocrurrcr! <br /> lo.lf Hie Incident occurred on a street or highway: <br /> Name o/slmef orNgAway A([he/nfersecNon ivilh or neamst intenrcUng slmN <br /> Rev.07108 <br /> i' -� <br /> / <br /> ... ._. ( /�.' <br />