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Clly olEwretlUsc Only <br /> Ev TORT CLAIM FORM <br /> R��'��.T��� <br /> a��.o��09 OCT O 1 2013 <br /> Pmsuant to Chapter 4.9G of lhe Revlsed Code of Washin9ton (RCW), �7[; T <br /> this (orm is far filing a tort dalm against the City of Everelt. Some oi �'�`,�'� �F�p p��Il� <br /> the in(ormation requesl�d on this form Is requlred by RCW 4.96.020 - -�- • <br /> and may be subject [o public dlsdosure. The Ciry Qerk is the City's ciry c�o�a a, n r� . �'( <br /> designated agent (or the purpose o( receiving daims. Clalm torms C � - I 3 <br /> cannotGesubm/Hede%ctronicalry(viae-nra!/or(ax). fj^ 1�00�5Jr <br /> ;PLEQSE,TYPE_ORP��TL�4�ARLY.tiN !ir:r �.1!��,I ...!����y:..v�:u 8...�.�.,.r.�_ f'�Z'!.7,\:,r' - , . . ��' <br /> I I�1K � ��., �. -�,:��, zs; <br /> Mail or deliver original signed claim farm to: O�ce of the City Clerk <br /> City of Everett <br /> Business Hours: 2930�Vetmore Ave.,Ste.1-A � <br /> Mon.-F!i.,8 a.m.to 5 p.m.,Padtic Timo Everett,WA 98201 <br /> Closed on city holidays <br /> CLAiMANT INFORMATION: <br /> 1. Claimant's name: <br /> .�,1� � I__ .. ., ��v'iv� T 07�21/l�•82 <br /> Lasf name ' fial F1:dd/e Dafe o/b/Rh(ntm/dd/y�yy) <br /> 2. Current residentlal address: � �0� �V�VcI•T/�'1!� <br /> 3. Nalling address(If differen[): �5�� ��s� �`�' N� �V��SV���C� w� (.gZ�O <br /> q`Resl en[lal address at lhe tl e of the Incident(If dl(ferent from mrrent address): <br /> A^S.A�uvlJ GV.�XV ui$ II <br /> ;. ClalmanCstelephone number. `— 2oG-�4U ���'4Z �-- <br /> l/ome Cc/l . �ut/ness <br /> G.Clalmant's rmall address: k��lV1q4� crJ�Aq+4HAi, ��^'� � <br /> INC[DENTfNFORMATION: � <br /> �. Date of Inddent: ? ?�o( 7�me :�`��_ L�a.m. ip�p.m. (check one) <br /> � mndd lyyyy) � <br /> 8. If lhe IncjdenS oaurreJ over a period of Ilme,date aF first and last occurrences: <br /> (rom:����I1T Time: 1'�0 ❑a.m. �p.m.(check one) to 4'6 '+A 7�,� 7ime:7�� ❑a.m. �.m.(check one) <br /> (mm/Jd/}�ryy) (mnVd IVVyy) �ll <br /> 9. Location of Inciden[: w� tSlw�vann.ls�. (a� ru�vfC1� �30� �.=�,e,t-C�1f��C. <br /> ' State and munry Crry,I(applicab/e C/ace rvhere occurreJ <br /> 10. 1f lhe Inddent occurred on a street or hl9hway: <br /> Namc ofstrcc:a�hl,jbN�y At fhe/ntersttt(on ir!(h a ncarest/nfcacct/ng sfine! <br /> Rov.07109 ' <br />