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i <br /> Clty of Evarott Uso Only <br /> �ECEI�I�,� <br /> Ev n TORT CLAIM FORM <br /> SEP 2 0 2013 <br /> flev.07/09 <br /> Pursuant to Chapter 9.96 of the Revised Code of Washington (RCW), �➢'�'4f�yF E'V��iETT <br /> this form Is for 811n9 a tort dalm agalnst the Ciry of Everett. Some of Ci�y�lr_r� <br /> the Informatlon requested on lhis form Is requlred by RCW 4.96.020 <br /> and may he subjert lo publk dlsdosure. The Clty Qedc Is the Gry's CilyClcAcClalm No. <br /> deslgnated agent tor the purpose of recelvlrg dalm;. Claim Iornrs '�7� L,� I 7 <br /> cvnnot be submitted e%ctronica/ty(via e-mai/ar f.�x). �I 3� 53� <br /> �_P.LEASET!VEOR�gRINT�CLEARLY`ININK�_��.�' � �--� :�:'� t..,;.�' .�. .;'< 5.r:��. .���1_.:_� �:Y.,.,:,'.,:1�;:I <br /> Mail or deliver original signed claim form to: Office of the City Clerk <br /> Cily of Evcrett <br /> Business Mours: 293D Wetmore Avo.,Ste.1-A <br /> Mon.—Fri.,e a,m.[0 5 p.m.,Vacific Time Everett,WA 98201 <br /> Closed on city holidays <br /> CLAIMANT INFORMATION: <br /> i.ClalmanPs name: <br /> ��r/i%s��� �/i yoh /� n9-a;-��<o <br /> [ast name Fi M/dd/c Oafe o/Girth(mm/dQ/yyyy) <br /> 2. Current residential address: /h �/ Cr���� i'��.r.,� ��f./1 it14. Tiflc/ <br /> 3. Malling address(if dlFferent): <br /> 4. ResldenUal address at Nie Ume of the Inddent(If diflerent from current c ddress): <br /> 5.Clalmant's telephone number: `/1•r'Zs�Y�/Ss/ _ _ <br /> Nome Cc!l Busfness <br /> 6.Cialmant's c-mal�address: _��� •�.ils���+ //r� �'—;�lJ�� '«y <br /> / <br /> C D_f1T INFORMATION:� <br /> 7.Uale of IncldenL• _Q� tY�J�/3 Time : .K7a.m. �]��.in. (check one) <br /> c mmJdd/riri)„ <br /> o� n� ,�o/} <br /> 0. If Ihe Inclden[occurred over a ierind of dme,date of Orst and Iast uuuimnces: <br /> (ranr. Tlme: ❑a.m. O p.m.(check one) ta Time: I I a.m. �J p.m.(check one) <br /> (mm/dd/W1'vl (mm/ddlVriY) <br /> 9. Loeatlon of Ineident• fJit - j,,,, e.;,,l� -- lr.�•-r H /�)1 ./•%n.-/! �Q,..vw.^ <br /> 56�te and rounly Cif}; l/apph�vble G/ace ivhem accurre,� <br /> 10. If thc Inddent o�curred on a street or hlghH�ay: <br /> I��.. <br /> Namea7sfr ta�h/gh�rdY Atlhelntasedlann7fhornearestinMrsecf/n9streef <br /> Rov.07109 <br />