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Glry ol Evo�on Uno Only <br /> RECEIV�D <br /> Ev rr TORT CLAIM FORM SEP o 3 2013 <br /> rt��.0�/09 <br /> Pursuant to Chaptcr q.96 of lhe Revised Codc of Washington (RCN�, CITY OF EVrl�ETT <br /> this form is for filing a tort datm agalnst thc City of Everett. Some of ���Cj�,� <br /> the Informatfon requested on this form is requlred by RCW 4.96,020 <br /> and may be subject to public disdosure. 7he Qry Cierk Is lhe Gry's G�y Clurk Clalm No.! <br /> �deslgnated agent for the purpose of recelving clalms. C/a/m fomu ���'U� (� <br /> nnotbe sutrm/tted electronica/ly(via e•ma!/o�/ax). <br /> k��ASEJYPF.QR:pRINT�CLEARLY.`TN!INK`:�',; ..._, .,.. '-?� ,°,�.:_ .:.' ' °;�...' w'�;,:r\ , � ,' ,,. . <br /> Mail or deliver original signed claim form too Office of the Gty Clerk � <br /> City of Everett <br /> Business Hours: 2930 Wetmore Avo.,Ste. 1-A <br /> Mon.—Frt.,8 a.m.to 5 p,m.,Pacific Time Everett,WA 98201 <br /> Closed on etty holidays <br /> CLAiMANTINFORMATION: I <br /> 1.Claimant's name: <br /> j�/�0 DNS '7�,[ci C 7 — 3./4J7,v <br /> [asi name firsY � Midde Oafe ofblrth(mm/dd/yy�ry�) <br /> 2, Cur2nt residential address: �p��� f,�L.r�b��r� w �J�e.� i r' Lt/,�} 9�2P�e _ <br /> 3. Malling address(IFdiKerent): �6.�ea(��.i'D L �i�� n�' (,O�3 9���L <br /> 4. Residentlal addrcss at the dme ef the Inddent(If dlfferent from current addmss): <br /> 5. ClaimanPs telephone number. __ yZ.r 7U- �/_ �_ <br /> Nome fe/l Ousness � <br /> G. Claimant's e•mall addrcss: ,__ (j/�6D!•'S /7 rb Q e FtZne-�art.Cn,-. <br /> INCIDEf�IT INFORMATION: <br /> 7. Date oP inddent: �'f�.�_ Time!.y�S' ���� ❑a.m. �p.m. (check one) <br /> (mm/d�/YVYYJ -7/�—.�L�''"''^"y I <br /> � <br /> 8, If the inddent occurmd over a period of time,date of first and lasl ocwrrenoes; � <br /> i from: Tlme: 0 a.m. 0 p.m.(check one) lo �Tlnm: ❑a.m. O p.m.(theck one) i <br /> (mrtVdJ/YVYV) (mR4dJlYVYY) <br /> 9. Locationofincldent: _LlL��1j�lj�ij�lr� ��'�csvfl�—_ ?�.?9 �r��v _ <br /> StaM and munq� Qty,lfepplirable Mam whcvr� <br /> 10. 1P the Incldent oaunnd on a street or hlghway: <br /> Namc ofstrret or h/ghway At(he lntenttti0n with o�nn+Tsf Infaseciing s7m V <br /> Rev.07NB <br /> �=� ' . <br /> � ' %r) <br />