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� <br />� <br />Rev.01/09 <br />TORT CLAIM FORM <br />Pursuant to Chapter 4.96 of lhe Revised Code of Washington (RCW), <br />thls form Is for flling a tort clalm agalnst the Ciry of Everett. Some of <br />the infortnation requested on this form Is required by RCW 4,96.020 <br />and may be subjed to publlc dlsclosure. The Gty qerli Is the City$ <br />designated agent for the purpose of recelving claims. C/alm torms <br />cannotbesubmltteddecfronical/y(v1a e-mailorfax). <br />Clty of EvoreK Uso Oniy <br />R�C��1�ED <br />�CT o s zo�� <br />�$TY O�P EVEI�IE'�'7C <br />City Clerk <br />Ciy Clerk Claim No. <br />p"�t�:�— I� <br />� ^r-• - -�� - - � - � T- . .., <br />.-._.r�.—.—.-�.-- . _.. . __ . _�. .., _ <br />iPLEASE�JI�PEUR.P..RII�TCLEARLY �IN�IPIK .._. _ . --� _...--" ___- _..r_v.r.: . .'- ' <br />Mail or deliver original slgned daim form to: <br />Business H�urs: <br />Mon. — Fri., 8 a.m. to 5 p.m., Paciflc Time <br />Gosed on dty hoildays <br />CLAIMANT INFORMQ1fION; <br />1. Clalmant's name: __ , _ <br />2. Nrrent resldentlal address: �,�,_l�,l <br />7. Mall�ng address (if different): <br />Offica of the City Clerlc <br />City of Everett � <br />2930 Wetmore Ave., SYe: 1-A <br />Everett� WA 98201 <br />tirst <br />�' OL3 <br />. . -,, � r:;,... <br />q. Residertlal address at the Hn�e of the incident (If dlfferent from current address): . <br />5. ClaimanYs telephone number. �z-S �ZZ- lv(�� <br />, � _ Wome � Ce/l <br />6. Claimant's e-mall address: <br />r of binh (mm/dQ/yyyyJ <br />�J� 9�Zc <br />Businrss <br />INCIDENTINFORMATiON: <br />/� r7 !�I <br />7, Date of inddent: O�/�� �� �ime : J'�� ❑ a.m. ,�1 p.m. (check one) <br />t�nm/ddlVvrv) <br />8, If the inddenl occurred over a period oF tlme, date of first and las[ otcurrences: <br />from: nme: ❑ a.fi. .L] p.m. (check ane) to iime: ❑ a.m. ❑ p.m. (check one) <br />(mmldd/YYYY) - - - , imml�lYYYY) . . <br />9. Locatlon of Inddent: <br />10. If the Incldent oaurred on a street or highway: <br />Rev. 0TI09 <br />�ry, <br />P/ace where <br />�._. ,�,� <br />Nameafsdeeto'rh/ghway AtMeinfersedionwifhorrrearestlnfrrsrcbbgsfieet � <br />