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�� CIty�O(lEvOrO�:oOn�� <br /> ��'d;.�� N�� { <br /> Ev rr TOIQT�'LAIM�ORM OCT o e 2013 <br /> Ncv.07/09 _ i,�+ <br /> Pursuant [o Chapter 4.9G.of tlie Revlsed Code of 14ashington (RCN'), �gu� �� �����A� <br /> this form Is for Ning a tort clalm ayalnst the City of Everett. Some of �'ifvr �'i��' <br /> !hc info.iiation reques[ed on lhls form Is required by ROJJ 496920 `� <br /> and may �e subject to publlc dlsdosure. 7fre City Cleik.ls the Citys CIIyCIarkCla!m�:o. <br /> ose of recelvinc dalms. elaim (arms n � <br /> designated a9ent for the pur{� .� �,y,� - � '� <br /> cannotbesubn�lttedelectronlcalty(vi,�e-mailorl.�xf. � O . <br /> �,.;. <br /> �LEASE�'T'PE-OR�.PRINT'CLEARLY:�IN,INK�;;�. ,���_ . _� - ._�'_'.. .... .._ . ...�` _' .`��.__ •.��,.:��..! � :?.�1 <br /> hlail or deliver origin�l signed claim form to: OHlce of the City�Clerle <br /> City of Eperett <br /> Business Hours: 2930 Wetmora Ave.,.5te.;1-A <br /> Mon.-Fri.,8 a.m.to 5 p.m.,PaclficTime Everett,WA 96201 <br /> Closed on city hoiidays <br /> CLAiMANT INFORMATION: <br /> � �c3 <br /> t. Clalmant's name: �-L��;JT C �-{" - �- ' <br /> ���,s,4� � cz �u�..cc � 7- ��- :�� <br /> Lasf n3me F/rsl ANQdk Datc of b/Rh(mm/dd/yyyyJ <br /> 2.eunentresldentlaiaddress: �_Q�L—�`�'��'<<� �`�s r�v'' �� �fy �� ga0� <br /> 3. htalling address Qf dlfferent): '— <br /> 4. Residentlal address at Ihe thne of lhe Indde�t(If dlffcrent from cu�renl address): <br /> 5. Clalmant's[dephonc numbec ��5_�I "� �10 ,--��"� -'���� "� <br /> l/ome Cdl tJus/ness� <br /> 6. ClalmanCs c�mall addres;: _�;_I��.r o 1�`:�'�'. C-`' .n^ <br /> iNCIDENT-TNFORMATION: ���� (� `� `�� � <br /> CJE-��� �-'l� �l I Lf1l,L�a.m. ❑ m. (chede ane) <br /> 7. Date of UicldenL• _.O�- � - 1�i lllnr,: ,�.{_. p. <br /> (mmJUd/yWY) <br /> e. If the Incident naurred over a pedod of tlme,dale of Orst and last octurrences: <br /> fmm: Tline: ❑a.m. f.l p.m.(check one) to, Tlme: ❑.a.m. CI p.m:(:heck ane) <br /> (mMAdIY✓YV) ` (mmlddlVYYV) �� <br /> 9.LocaUon of Inddent �����_�v�vu',1��_ .. �-. r ��� j_��lG ��'�-�1--_���`���'�"—�'���?'-""^' <br /> - Sfah und counry�J C/ry;l(appl'c�G.�c Phcr.ivfterc acrurred <br /> 10. 1(the Incldent occurred on a street or hlghway: _ <br /> - - Yemee/sfreelorh�ghway titfAe/nferserlionnNhornearrstinfc,secln.GshcU <br /> Rav.07l09 _ <br />