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-- Evei I a � <br /> TORT CLAIM FORM OCT 0 3 2013 <br /> n.v.o�/os 6.�X I QF EV���d 1 <br /> Pursuant to Cliapler 9.96 of the Revlsed Code af washington(0.cW), C+�� Cl�,� <br /> th6 form Is far fJing a tod clalm agalnst thc pry of Everett. Somc of <br /> the Informatlon rcqucsted on Ihts fartn Is required by RCW 4.96.020 , <br /> and may he subJect[o public Alsciosure. lhe qty Clerk Is Ihe Clry's �°Y�'�`a'°"N°. <br /> deslgnated agen[for the puqwsc o(recelving dalms. C/a/m furms '� ' t� � <br /> canno[besaG'mlKed alactronkelly[vla o-nrall orlaxJ. , � Q(� 5 b <br /> PLEASE TYPE OR PRINT CLEARLV'IN INK � <br /> Mall or detiver orlglnai slgned clalm form to: O(flce o/the Clty Clerk <br /> Clty of Evaett <br /> eustnass Hours: 2930 Wetmore Ave.,Ste.1-A <br /> Mon.—Frl.,8 a.m.to 5 p.m.,PaciflcTime Everett,WA 98201 <br /> Closed on dty holldays <br /> CLAIMIINT INFONMATION: <br /> -. 1.Clalmant's name: <br /> �r 4�.w I� /'-j-;1�— A � i.t., ys% <br /> Last name F/rs! M/ddle Dafc of ith(mrq/Gd/yyyyj <br /> 2.Qmentresldentialaddress: __f.��f�C7� LA'��P-N1� <br /> 3.Malling address pf Qlfferent): �$1�1+�-Q- <br /> a.Resldentlal addrcss at the tlmc of the Inddent Qf dlffemnt from cunent addmss): <br /> 5.Ctalman['s tclephone numbcr. _'� 'G�[Lz� '�� Z����b <br /> ��� �llom�e""� `" Ce0 •� Utulness <br /> G,Clalmant'se-maliaddress: —.(��..—o..--�-,��*��L�7Gli�.C-�zb <br /> �fJCIDENT INFORMATIGN: � <br /> 7. Date ol InddenL• � X Tlme: O a.nt �p.m. (chcck one) _ <br /> " '-�mmr a! ) <br /> 0. If the Inddent otturred over a pedod of time,date of fnu arel last acarrcnces: <br /> fmm: Tlmc:__l7a.m, Up.m.fcheckaic) to_ Timc: ❑a.m. fJp.m,(dicckonc) <br /> (mmlAJM'YY) / , (mMddlrirr) <br /> 9.Lcxatlon of Inddent:���!'���`�•� --- .y�J����<<'e--- <br /> ` -Sfafe and munry ry,!(applira� Wvx ivhtm ottarrid <br /> 10.If lhe Intl1dent otturmd an a street or hl9hway: <br /> Na olsfaclarhy7Mrey Af�AeDrfeRrcfioniNMrancvm�NnlnserUngslrcrt <br /> Hw.07108 <br /> /,� �� <br /> �f� <br />