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City ol Evcrcl[llso Only <br /> R�CEIVED <br /> Ev rr TORT CLAII►9 FORM <br /> SEP C 3 2013 <br /> Hev.07)09 <br /> Pur�uanl to Cliapter 4.96 of Ihc Redsed Code nf VJashln9lon (RLW), ���'y OF EVB�ET7C <br /> thls !orm Is for filinp a tort dalm against lhe Ciry of Everett. Some of ���� <br /> the information requested on this Porm Is required by RCW M1.96.070 CilyGerkcrmAe. - <br /> and may br subject to publit disclosme, The Clty Clerk Is Ihe Cily's <br /> deslgnated a9ent for thr purpose of receiving daims. Lla1m fornu �(�� � ` � � _ <br /> cannol Ge suGm/tted elect�anlca/ty[via e-mai/orlaxJ. <br /> FLEASF TYpE OR PRINT CLEARLY IN INK <br /> Mail or deliver origlnai s�gned clatm form lo: Otfice of lhe City Uerk <br /> City of Everett <br /> Business Hours: 2930 Wetmore Ave.,Ste. 1-A <br /> Mon.-Frf.,8 a.m.to 5 p.m., Paciflc Time Everett,WA 98201 <br /> Closed an city holidays <br /> CLAIMANTINFORMATION; <br /> 1. Claimant's name: <br /> M�A�t�,� "�nv.ra� ntit�1- ti JG/6� <br /> Las!name (irst hJ/ddlc LHte n Lir�(mm/A�yyyy) <br /> �Q�—2.Cuiren[resldenllal address: 2� 3 �- � — <br /> 3. Malling adAress(if dlKemnt): — — <br /> 4. Residentlal address at the tlme of the incident(if different from turrent address): <br /> S.Cialmant'stelephonenumber: �f2� 8�"��"� w� L �G�� � <br /> No�ne_ C ll Ouslness <br /> 6.dafman['s c-mall address: d�1 'L4iGll�jl��.'a—I'�`������d�W <br /> i <br /> INCIDENT INFORMATIONt <br /> p`! �' ❑a.m. [9 p. (check anc) <br /> 7. Date of incldenU _i1/L 1 �3 __— Tlme: _� <br /> r�d���l»'ri) <br /> 6.If lhe Inddent occw'red over a pedod of lime,daie of fiis[and last om�rrentes: <br /> (�m: 71m���. ❑a.m. []p.m.(check one) lo_._nme:--�a.m. U p.m.(check one) <br /> (mMdd/YVYY) (mMJd/YVYY) �7 <br /> 9.Location o(Inddent: llu�' �UUW�?li�-U�Lz�i�� t'���'�--� <br /> StaManAcainty C�ry,1/appl/tab/e Placewherroccviml <br /> 10. if tlte Inddent ocarreci on a sheet or highway: <br /> Na�alshee!ofh/9hnay Atlhclnferscdbn�vith w rtevmsf laM�seding stme! <br /> RCv.07109 <br /> � <br /> �., ��Ti <br />