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RE��� <br /> TORT CLAIM FORM SEp 10 2013 <br /> n�v.o��os . <br /> Pursuant to Chapter 4.96 oF the Revlsed Code oF Washington(RCIh�, CITY OF EVB�ET'�' � , <br /> this form Is for filing a tort daim against fhe LYty af EveretL Same of C'ih C1CjJ( <br /> the Informatlon requested on thls form Is requlred by RCIN 4.96.020 �� <br /> and may be suhJed to publlc d(sdasurc. The City qcrk is the Glys cur c�cwm No. <br /> deslgnatcd agent for the purpnse of recetving dalms. Glo(m Jfarrxc �I (7j I �j <br /> unnot be sabmlMsd e/ectron/ally(v!i e-mel!orbx). � y� <br /> PLEASE TVFE OR PRINT CLEARLY IN INK <br /> Mell or deliver orlylnal slpned c1alm fam to: Offlu dthe City Clerk <br /> Cily of Everett <br /> lu�lnaa Hours: 2930 Wafnwro Ava,SLe 1-A <br /> Mon.—F►I.,8 a.m.M 5 p.m.,Paciflc Time Evarolt,WA 9s1D1 <br /> tlosed on ciq holldays <br /> , <br /> 1. lmant's name;� � , � <br /> L � 01 / <br /> (asireme � Ftrsi M/aNle /ol� rfh(mrtt/diMfY1 <br /> 2.CLrten:residentlal addreu: ,1d"_� "/� <br /> 3. Malling addras(I(dif(erent): <br /> 4. Residentlal address at the tlme of the tnddent(If dlHerent from wrten[address): <br /> 5.Ua�mant's telephnne number: �l�y,���'� l�n1 �U�✓ l �I <br /> e • u eusmea <br /> 6.qalmanCse-ma�laddress: l](1171'IP�.G�dl/11� v' I • Al�'1 <br /> INCIDENTINFORMATION: <br /> 7.Date of Inddent: U � �^ I � Tlme: �Ov � . a.m. ��. (chedt one) <br /> (mMa ) <br /> 8.if the Inr�dent acurred over a perlod of tlme,date of first and last accurtences: <br /> f�om: itme: 0 a.m. 0 p.m.(check one) ta Time: ❑a.m. 0 D•m.(rheck me) <br /> (mm/adlWyY) �^ �(�111 � (mmled/ryry) - /U. <br /> 9.lnwtlan of InddenL•��w/���� ln �'V/�• �g Li Dn7at�� V(1�1P/Y,��,/�" <br /> S��fa anOmunty � Q�Y,lfappllrab;e Maa whem ocruimd <br /> 10.If the Incident ocwrred on a sheet or ldghway: <br /> ,w�aaehramm�war arn��,a,�n�w,»�a�,r�ei�rmm��nsvKr <br /> w�.mras <br /> _-� <br /> ; � / f � <br /> ��„ <br /> �• <br />