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a <br />�� <br />�U��.3��� 1 <br />� �ur oi E..n�� u�o o�i <br />RECEIV�� <br />TOIe�CL�IIM �Od�IN <br />Pev.07/09 <br />Pursuant to diapter 4.9fi of Ihe Revised Code of Washing[on (RCW), <br />lhis (orm Is for filing z tort claim agalnst the City of Everett. Some of <br />tlie Informalion requested on thls form Is required 6y RCW 4.96.020 <br />and may be subJec[ to public disdosura The Clry derk Is lhe Clty's <br />deslgnated agent for the purpose of teceiving dalms. Llalui fonns <br />�annnt be wbm/Ked electror,lcaJfy (v!a e-mall or lax). <br />SEP 2 5 2013 <br />CX1'Y �F EVER�'P'd' <br />City Clct�C <br />IIyClakGaln �o ^ <br />nl �� � 1 .Yi <br />._._. .... .. __ <br />�PLEA§E T1fPE OR.PRINT CLEARLY IN INI{ , , . .` . ' <br />. .. ` � <br />Mail or deliver original signed clalm form to: <br />Buslness Hours: <br />Pton. — Fri., 8 a.n�. to 5 p.in., PaciFicTime <br />Closed on city holidays <br />�MANT7NFORPIATIQI4: � <br />1. Oalmant's name; <br />OfFlce of the City Clerlc <br />City oF Everett <br />2930 Wetmore Ave., Ste: i•A <br />Everelt, WA 98201 <br />L OI /Z�l//9 <br />[astnmire na: �•��w�� ..e��w�„„�..�.vwnr�si <br />2. Cunent resldentlal address: 2 SC% F-ESG�FLANo AVE <br />3. Mailin9 address (If dtfferent): S� nte <br />4. Residen[tal address at the tlme of the Incldent (If O:fferent from current address): <br />$a�vie <br />5. dalmanYs telephone number: ,�2S� 2�9 35�3 �%3� �7� S��y L�ZS 3�17. 75z2 <br />Nome CL+'I Busnm.s <br />6.CIaImanYsc-mailaddress; .___�RL��U�i�2✓�il._I���T2�`-�_corm <br />INGIDENTINFORMATION: , <br />7. Date of incldent: __ � �Z�� ''��� Tlma : �� �' `� ❑ a.m. �m. (check une) <br />(m�Ndd/yvyyl <br />B. If the Inddent ocarred over a pedod of Ume, da[e of Ors[ and last occurrences: <br />fmm: � T�me: ❑ a.m. � p.m. (died<o�) to ilme: ❑ a.m. 0 N m. (dicck ane) <br />(mm10NYYYV) � (mnVdOM'YY1 <br />9.Locatlonoflncider.t7 � Snoho�yjs�_l�. _�vE CLL_ l3�2��2 � �ti„ /�ve <br />/v <br />S7alc e Cmunry �o'ry, /Iepp.4caWc � Plare where occv <br />10, If Ne Incide� occwied on a street or hl9hway: <br />.-- n%�H- <br />Rav.07/0B <br />�,� + • <br />��'��- . <br />