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� �—q - <br /> R�v��� V f���� <br /> � n TORT C! ;tM fORM SEP o 6 2013 <br /> Nev.07/09 <br /> Pursuant to Chapter 9.96 oF the Revised Code of Washington (RCW), CITX O��V�CtET�' <br /> thls (orm is(or filing a tort daim agalnst the City o(Eve�clL Some of C�(7�,'�� .. <br /> [he In�ormatlon rcqucsted on lhis (orm Is requlred by RCW 4.96.D7.0 v <br /> and may be subject to pu611c dlsclosurc. 'Ihe Oty Gerk Is the Gty's Cily Clo�k CIa4nNo. <br /> deslgnated agent for lhe purpose of recelving clalms. C/alni iomrs `� �'�( — �� <br /> cannof Ge submRted e%ctroniw/ty(v/.�e-mal/or/axJ. o0 <br /> . . . . . . . , . . . ...�. . . . . . , . <br /> PLEA_SE:S�YPE.OR:PRINT.CLEARGY :IN.INK`. ' ' �- • <br /> Mall or dollver oripinal signed claim form to: Oflice of the City Cle�tc <br /> Cilyof Everett <br /> Business Hours: 293�Wetmore Ave.,Ste.1-A <br /> Mon.—Fri.,8 a.m.to 5 p.m., Paclflc Tlme Evere[t,�YA 98201 <br /> Closed on city holidays <br /> CLAIMANT INFORMATION: <br /> 1, qalmant's name: <br /> A�� IN�'FR �,�lMo �-�-3� <br /> Casf nvme ' qrsf � M/dd/c pufc o!M'rth(mn�dr(/yyyyJ <br /> 2. Currentresidentialaddress: 7zl C2J1✓� �/�1�✓� , LCUGsC CTr . 6✓iJSff 1�'3n� <br /> 3. Malling address(if dlfferent): _ _ <br /> 9. Resldential address at the tlme of the Incident(If d1lferen;(rom cunent addrets); <br /> 5. Clalmant's telephone number: .�,1l.15b �3LG _yl1 37� G�J7J <br /> Nome LLII 8uslncss <br /> G. Claimant's e-mall address: <br /> INLIDENTINFORMATION: <br /> 7. Dale oP Inddent: _ � ��— /� Time: _��-'u� _ L7 a.m. GSl p.m. (check ane) <br /> . (mm/ddlYYYY) <br /> 8. If lhe Inddenl occUrred over a perlod of lime,da[e of Orst and last ocanences: <br /> (mm: _Tlmc ❑a.m. f7 p.m.(check one) lo 'flme:,___[J a.m. LI p.m.(ch�zk one) <br /> (mm/dq/yyyy) (mm/dd/ryyy) <br /> 2LocationoflnddmL• ItiA$la,�sn/nNviY�f/l, �vl�2E�1� -�f/ ('/�a��N Q2/�/� <br /> Sfafe and munty 07�;lfapplirab/c P/acr Khc�c oavrrtd <br /> 10. 1(the inddent occurred on a st:eet or hl9hway: , <br /> NameofsGrrforh.gAnay � ANhcln(r.rsnYkniclfhornnvcsf/nMsn.iingnLr:! <br /> Rev.07109 <br /> / '� <br /> �/� <br />