Laserfiche WebLink
� <br />pev.07/09 <br />TrRT CLAIM FORM <br />; Pursuant to Chapter 4.46 of the Revised Code of Washlnyton (RCW), <br />'� thls form Is fnr filing a tort claim agalnst the City of Everett, Some of <br />;� the In(ormatlon requested on this (orm Is requlred by RCW 4.96.020 <br />�j and may be subject to public dlsclosure. The City Cleik is the Ciry's <br />;I deslgnated a9ent for the purpose of receiving clalms. Claim forms <br />; cannotGe subm/lted e%ctmn/ca/!y (v/a e-mal/ or fax). <br />SEP on 2oi3 � <br />C]�('X OF EVEY:E'I'i' <br />Cify Clerk� <br />. .�_._ .._._..._.. _.., . , - .. , . � . :..I <br />�PLEASE:,TYPEO �P. N7`GL'E%1R_l•Y''IN�YNK 1-- ._::` ':., ... _.. _ -... .-...-- _---: :-. <br />.--_'.1_ 'L�. �.. �___ . _. ' '— ' "' . <br />Mafl or deliver o'riglnal signed clalm fotm to: <br />Buslness Hourso <br />Mon. - Fri., 8 a.m. to 5 p,m., Paciflc Time <br />Ciosed on city holidays <br />CLAiMANT INFORMATION: <br />1. Clalmant's name: <br />Offlce o� the Lity Clerk ��& Mrs Rlcf�ard Shaver <br />Cliyl Of EVOI'0i � 4936 Dugwoad Dr. <br />2930 Wetmore Ave., Ste. l-A ! t��rcc�, WA 902033162 <br />Everett, WA 98201 <br />�i,cANi'�P�' �. <br />Af/dd/e na� <br />2. Current residential address: � `I 3 � �D � �' �-✓�� � `'L � �'' ' <br />3. Malling address (If different): f��= � �� , L`J'`� 5� Z� � <br />4, Resldential address a[ the time of the incldent (If different from cmrent address); <br />5. Claimant's telephone number: �'-S=-�S-�� �y� 3 <br />Name • <br />6. Clalmanl's e-mall address: <br />INCIDENT INFORMATION� <br />7. �ate oP Incldent: j' ��-� /� 3 <br />— (m d /�) <br />Ce/! <br />.r�_ 2— � �r <br />3 ��-37 <br />Bus/ress <br />Time : i—' 7 0 a.m. L3��p.m. (check one) <br />8. If the tnddent oaurred over a perlod of tlme, date oF first and lasf acairences: <br />from: _ T(me: ❑ a.m. 0 p.m. (checl; one) lo �mM��Uv»'v) nme� ❑ a.m. � p,m. (dieck one) <br />(mmJddlVVYY) , <br />9. Locatlon of incident: <br />10. If the Incldent oaurred on a street or hlgliway: <br />wirh <br />Rav.07109 <br />, �.,� � <br />�i.. _ <br />