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. .v r u e rl <br /> �' TORT CLAIM F'ORM SEP 19 2U13 <br /> "`".°"°, CITY OF EVBRETT <br /> Pursuant to Oiap[cr 4.96 0!the Revlsed Code.of Washington(RCW), City Clerk <br /> th's form Is for fillrg a mr;dalm agalnst the qty of Everett. Some of <br /> che Informatlon requesteU on this form is requlred by RCW 4.96.07.0 <br /> and may be subjecf to publlc discbsure. The Ciry Clerk Is the Olys Gly Ged q�hn No. <br /> designated agent for the purpose of recelving clalms. C/alm/orms 'b���� — �3 <br /> cannot be subnr/tted e%ctronlce//y(vla a-mai!orfaxJ. <br /> pLEASE TYPE OR PRINT�CLEARLY 7N INK - � � <br /> Mail or delivar original slgned claim fomi to: Office of the C�ty Clerk <br /> Clty of Everett <br /> Buslness Hours: 2930 Wetmore Ave.,Ste.i-A <br /> Mon.—Fri.,8 a.m.to S p,m.,Paclfic Time Everelt,WA 98201 <br /> Llosed on clty holtdays <br /> CLAIMANT7NFORMATION: <br /> 1.qalmant's name: <br /> _..0 �.��,� _.. �� . _.C-: _. oa/r9/�9�3._. .. <br /> [aslname Hrsf Middlc Daleo/bfrM(mni/dQ�rygy) <br /> z.Curcent residentlal address: 1-1 S a b W e�t� �i�,�,d 1 t;J t,�v e�e.'l'l� W A 9 8]O�i <br /> 3. Malling address(If dlfferent); <br /> 4.Resldentlal address at the tlme of the Inddent(If difierent(rom arrcnt address): <br /> 5. Galmant'ste�ephonenumeer: �4�:1Sa-�l�►l� (!+at7aao-35oa _ <br /> Hnme [NI BuAness <br /> 6.tlalmant's e•mail address: <br /> INCIDENTINFORMATION: <br /> 7. Date of Incident: _�q�01�—_ Tlme: ' I�a.m. �p.m. (check one) <br /> (mirJd�UvYW) <br /> e. [f the Inddent occurred over a pedod of tlme�date of Flrst and last occurrenms: <br /> from: Time: ❑a.m. CI p.m.(ched me) to Tlme: ❑a.m. C]p.m.(check one) <br /> (�l4NYVVY) (�^!dd/YYri) <br /> 9.Laallon of Incident: IJn<I.'..�"f�� �S..el,e,.,�_.l, �F u � - <br /> 57afp and roM O'ty,Nnppllwble Plam wfiere ocruned <br /> 10. If the Inddent occurred on a stmet or hlghway: , <br /> i i i n H��,;�44 Aa�„4� . <br /> nwx an.nran,gnw,y At Me 1nRxnfbn wIN a'ncarest M(erserNngsfrret <br /> Rev.07lOB <br /> � <br /> / ' <br /> Y1//�.� <br /> \�<" <br />