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Clty of Everatl Uso Onty <br /> RECEIVEP <br /> �TORT CLAIM FORM <br /> Rev.07/09 SEP o 9 2013 <br /> Pursuant to Chapter 4.96 of the Revised Cade ef Washington (RCVJ), �'������+.r <br /> thfs form Is for filing a tort claim against the City of Everett. Some of ��i 1 <br /> the information requested on this form is required by RCW 9.96.020 �(� <br /> and may be subject to;public disdosure. The City Gerk is the City's CIryC�erkclalm o. <br /> designated agent for the purpose of receiving claims. Ga/m forms n�OG)— I� <br /> cadnot be submleied electronlca//y(vfa e-mafl or fax). ��1��y�b� . <br /> � - - --- . _.__ _ . . . .. .. <br /> � _�___----� ----•--•--- ---- • -.. <br /> tPLEASE_TYPE OR�PRINT CCEARLY_IN INK _... . . _. . - - -- ----- . ... . :. _ _. _ _ .�.,_. : ,._ ._ 1 <br /> Mall or deliver orlginal signed dalm form to: Office of the City Cierk <br /> City o•;Eveiett <br /> Business Hours: 2930 Wetmorc Ave.,Ste. 1-A <br /> Mon.—Fri.,8 a:ln.to 5 p.m.,Paciflc Time Everett,WA 98201 <br /> Closed on city holidays <br /> CIAIMANT INFORMATION: <br /> 1. Clalmant's name: ry� <br /> /'/i ��P/ �j�/c�i� / �'7• �6��,7�/9 ��i7 <br /> lasiname first Middle Da ofbl (mm/dd/yyyyJ <br /> 2. Current resldentlal address: ��Z� �/����`� adc'i, �✓ei-G77� wQ - �g��� <br /> 3. Mailing address(if different): , <br /> 4. Residential address at the time of the incident(if differen[from current address): � <br /> � i� <br /> � <br /> 5. qaiman['s telephone nwuber: 5�7_S 3�5: 972R <br /> Nome Ce/l Business <br /> 6. Claimant'se-mailaddress: /�7/�SPrI�://e/''i[�/�(oinCqt� �� ' _ <br /> INCIDENT INFORMATION: <br /> . •:�i <br /> 7. Date of fncident: • G �3 � ,Time,:��avl� 7'DO��' a.m. p.m. (check one) <br /> (m dd/yyyy) ., <br /> 8. If lhe incident occurred over a perfod of time, date of fi�st and last occurrences: <br /> from: Time: a.m. p.m.(check one) to 11me: a.m. p.m.(check oitej <br /> (mm/dd/ryyyl jmm/dd/yyyy) ' <br /> 9. Location of fncfdent: �(/4s�• � S/10�oJp/sH GUP�'�7%�' �OZ/ �iQiO/1 Y u✓� e8z�'/ <br /> Sfate and munty Gty,i(applr�able Place wl�ere ncrmreA <br /> 10. If the fncident oaurred on a street or highway: � , � <br /> Namc ofsYrtrt orh/ghivay At fhe/nfeise¢riun�Wfh a neares?lnterscrtlng sbert <br /> . Hcv.07l09 <br /> ,' � 17 ,� <br /> J / L.; <br /> l ! <br /> �� <br />