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� <br />� <br />. . � �°��3e�� ( <br />� <br />TORT CLAIM FORM <br />�...o�i� <br />Pursuant ro Chapler 4.96 of U e Revlsed Code oF Washingtun (RCW), <br />thls form Is (or flling a tat dal��n agalnst Hie Uty of Everett. $ome of <br />1he In(ormatlon requested on nls form Is requlm� 6y RGW 4.96.020 <br />and may be whJed to publlc dls-lasure. The Qty derlc Is the Clty's <br />designated agent for the purpose oF recelving �alms. C/alm /ornrs <br />canirotberuGm/tted dectron/calty(via rmallarfaxJ. <br />CI{y ol Evarett U�e Only <br />���JLJI 7 ��+ <br />SEP 2 6 2013 <br />CI'Y'Y OF EVEYi�T"I' <br />�l�V L'1!i'?!. <br />Gly Clak CI o. <br />� I��j -' �7' <br />;�!�EaSETX�:07t':FfiRiNT�GTLEARLI��IN-IN�=�!.` w _�t�t.S��i,.:t��.�'.-:_s. _..':.._� �'_i; �.�T.::�+;w��:� <br />Mall or deliver odglnal eigned deim form to: <br />Oueiness Nours: <br />Mon, - Frl., B a.m. W S p.m., PaciFic Time <br />Ciosed on dty holidays <br />CLAiMANT INFORMATION: <br />� 1. dalmant's name: <br />�J'�j'MLr.fen/ /Za.t.1� <br />[asineme F7rs� <br />p <br />Offl� of the City Clerk <br />City of Everott <br />2930 Wetmore Ave., Ste. l-A <br />Everett, WA 98201 <br />/.tii 'Jf"/ �' / `%�� <br />2. Qirrent msldential address: -� � p r r�n�'� �CN L�` <br />�� <br />3. Malling address (If dlfferent); <br />4. ResldenUal address at lhe Ume of [he Indden[ (If dlfferent from nurent address): <br />��a� r[rOFK/�L Irv�N✓L� � ELcrit.��7/ Gv9- �%i% Lo� <br />5. C]almant's te�eptrone number: �— _ C�''�% �s7 •/^"3J (�'e.r� Z� L� 2/JJ <br />Homn _ Cel/ . Buslness <br />6. tlaimant's e•mail address: r' ° 1 s �� <br />INCIDENTINFORMAttON: <br />7. Da[e of Inddent: /� 2 9 2u/3 T1me :_6 �Va � a,m, pt p,m, (chedc one) <br />f�leN ) <br />A. If the Inddent occin red over a perlod of llme, dateof flrst and last acurren�esi G"/v �/�C✓ f <br />from: �°d G Time: � � a.m: 0 p.m. (chttk one) ta �� 3 Timc: — ❑ a.m. 0 p.m. (dierk�one) � <br />(mm(dd/yyyy) � (mMdd/yyyy) <br />9. Loratlon of Inddent: �"�f/�/^'� �"� i ftiu/loN2ifF/ c.•ouwTy ��-cn�7� irc.rs:�9cam.� <br />� � Sfafeandmunty Clty,!/applbb�e N'acewl�creacr.�vrad <br />10. If the Inddent oocurred on a itree[ or hlghway: <br />r�-� �n�-` ;�-�,��� ,t�L� � � "' �'r��r•r- <br />Nanx oJsfrce! crh/yhway At fhe lnfe!mlia7lMfh crreartst MhrstCingsf2M <br />RN.47109 <br />