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� <br />�. <br />�.. o�/o� <br />TORT CLAIM FORM <br />Pursuant to Chaptef �.% of the Revlsed Code of Washing�on (RCW), <br />thls form B fa flling a lort daim agai�t the City of Evuett. Sane of <br />tfie Infottnatbn n.quahd on this Form Is requfred by RC1N �.96.020 <br />and may be subJed to pubNc discbsure. The City delk fs the City's <br />designabcd agen[ for Me purpose af receNring clakns. C�6fin hmn <br />aN►nat M�d ekcbvnk�Ay(rii e-ewvxli,rJ. <br />�eT�fiid; .blt R�;u�iu��r �sN>nNl <br />Mail or ddhrar aiyinal �iyned daim form ta: <br />lufHllfs IIOUfs: <br />Mon. — Fri., / a.m. Eo 5 p.m., Pacifk 7ime <br />CbseA en dq lalidalrs <br />R��i�'ED <br />NOV 13 2013 <br />�IT'X OF EV$�TT <br />c�iy C�!!� <br />OfBa d tha Gty perk <br />Cily of Eve►ak <br />2930 Nktmoro Ave., Ste. l-A <br />EveroR, YIIA l0201 <br />4. ResMentlal address at the time aF the inctdmt (If dilferent from current address): <br />S.Claimant'stekplronenumber: �}�i�-(odg�-9R�f� 'j�•S'itS.2�3U,33 �i1S^.ZSZ'.3�� <br />/I{a71B • C�ll Bf/Si/IlSS <br />5. claimanCs e•maH address: E"i'TlQnwfi�W 47f ��%t�91 �. • CON�1 � <br />INCIDENTINfORMATION: <br />7. Date of Incident: 0 l Time : <br />( �lvNYv) <br />B. if the Inddent acurred over a perbd of time, daM o► Ors[ end last oaurrences: <br />from: TMne: O a.m. 0 p.m. (chedc one) Oo Time: <br />(mn/dd/riNV1 _ (mm/dd/YYYY) <br />9. Laatlon of inddent: <br />�-�^�.�.�Y'!! h <br />10. If the fnddent oaurred on a sheet or highway: <br />❑ am. ❑ p.m. (chedc ane) <br />❑ a.m. O p.m. (thedc one) <br />im,uorsrmddnyniwr �taheNHrsecamnia,a-nev,earxersaa�gsneer . -. � <br />