Laserfiche WebLink
Ciryof evenn use oniy i <br /> - RECEI�IED � � <br /> ,,; ,Etr . . TORT CLAIM f'mRM ' <br /> R��.o��� - SEP 0 3 2013 I <br /> � i I <br /> Pursuant ta Chapter 4.96 of the Revised Code of Wa;nin9ton (Rcw), CIT'Y OF EVERETT ' <br /> this form istar flling a tort claim agalnst the City of Everett. Some af <br /> the information tcyues[ed on this form is reqWred by RCW 9.96.020 City Clerk : <br /> and may be subJect to pubiic disclosure. The City Clerk is ttie Ciry'S CIryClerk CIaIm No: <br /> designated agent (or the purpose aF receiving claims. Cla/m lorms b��7 g� - ��2� <br /> canno[be submltted e/ettronlcalty(vlv e-mar/or laxJ. - . . . - <br /> P��A.R.�iTcYP,E�.ORiPl��T,CLEA1�l.Y'IN�k'. � .� t�:C: , i .. � . . 1�':' , ;�,.-, ,•,,,; :. 1 <br /> Mall or deliver originat slgned claim form to: Office of the City Uerk <br /> City of Everctt <br /> Business Hours: 293o Wetmore Ave.,Ste. 1-A <br /> Mon.—FrL;8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 <br /> Closed on iity hoHdays <br /> � <br /> C�AIMANT INFORMA'i�: • <br /> i.Claimanrs name: <br /> ^ .�:Et2(�- __ J�,-,�-fi- -rr�a�T , o�l-z,- ��1c.3 <br /> last name . . . ._. �'list . MrddM . Date o%birtfi(mm/dd/YYri') <br /> 2.Current�resldential address; �C�� _�aSk ��n�� l=Jere.+� w4 ��7_Q � <br /> 3.Malling address pF dlfferent): � StL�X. <br /> A.Residential address at the time of Ihe incldent((f different from current adAress): <br /> _ .. .�RmP_. .,. .. _. .. . _ . .__ <br /> s.daimant's telephone number: ��� •� 3�.,_ yZS -451q-�`��0 !F25.-3T1-3'L3 4, <br /> � Hame . Cell Busines . <br /> 6,Claimant's e•mail edd�ess: ��"1_be�n � �c)��7.��rn�i�� . I.�___ <br /> �ID�NT I�IFORMATION: <br /> 7,Date af`Incident: . d��.7 ��,� I ad�3,� Time: .1�. vu. 0 a.m, �,p.m. (check one) <br /> (mm]dd/yyyy) <br /> 8.If the Inddent occurre6 over a period of Ume, date of first and last occurrences; <br /> from: Time: ❑a.m. [l p.m.(check one) tn Time: ❑a.m. O p.m.(check one� <br /> (mn,/ddlyyyy) (mm/dd/yvyy) <br /> 9.Location of Inctdent: J.�' S� (,)< A �Ur Ic_4-� 2.?n'� �. G/Q�! H..r. . . I <br /> Sfafe and mu�iry pty,ifappll�ble Placr k�enr eccvrred <br /> 30.If the incfdent acwrred on a street or highway: <br /> � � Nameol5tre+etOrhigh�Kry ;ftlielntersec4�onwffho�ncwrsflnhnrci/ngsireet � I <br /> ��� / ` / <br /> � <br /> /^� <br />