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i <br /> C{ly ot Evo�att Use Only <br /> I�EC:�I�1E� <br /> Ev rr TORT CSA.IM FORM' SEP 1� 2013 <br /> ne�.m/ov <br /> �o �u� <br /> Pursuan[ to Chapter 496 of lhe Revlsed � �de of Washln9ton (RCW), 4��11��������� ' <br /> this form Is(or fling a tort dalm agalnst lhe Clty of Everett Somc of �i� Cj�� <br /> the Informatlon requeeded on thls form Is required by RCW 4.96A20 �IryClarkLlrlmNo. <br /> and may be subject to public dlsdosure. The Clry Clerk Is lhe Qty's �a3 -. i 3 <br /> deslgnated agent lor [he purpose o( ieceivhi9 ctaims. Gaim forms <br /> canno[LesuGmlttedeleclranlcally(vloe•ma!lo�fax). ' � ��e� &� <br /> �y., t. !�: , �: y "I <br /> ��LEASE�T.YPEOR�I'RIN��CLEARLY�EININIGi,cr ;: � .,�.� ,,, J,iii.:;�.ctl 3, :.�'�.:r.. ��.,;--i .,.. ... <br /> Mall or dellvcr nriglnal slgned clalm form to: ��ty�of Everett'ty`�erk <br /> Ousiness Nsurs: 2930 Wetmore Ave.,Ste. 1-A <br /> tdon.—Fri.,8 a.m.to 5 p.m.,PacificTfine Everett,WA 982D1 <br /> Closed on city holidays <br /> CLA7�dANT INFORMATION: <br /> 1. Ciaimani's name: <br /> � � p 0�/�/ ia77 <br /> [as� ������'"� ��� Middle Dafco/blith(mrNdd/yyyy) <br /> � f�rsf <br /> 2,Nrrent resldenlial address: ��3a u� '� � t—' f J'��� �"A Q��' <br /> 3. I4alling address Qf differenij: <br /> 4. Residentlal address at the time of the fnddent Qf dlfteren[from curren[address): <br /> o c� Nas-��S- 3�� <br /> ;, Clalmant's lelephone numher: ��---�—�— pusiness <br /> Homc I Cell <br /> G. Clalmant's e-mall address: C�i�M[1_C��1�' mn� [�� .. - <br /> �nir�ncry'1�INFORMATION: � <br /> ' 7. Date of Inddent: g�_��`� Tlme: L'_�'_3!� ��+•m• p•m. (check one) <br /> (mn•Idd/YYYY) <br /> �. If the Inddrnt ocarred over a petlod of time,cy�te oF first and lasl occurrence;: J <br /> .�_I�q.J_I�TI���°��}�--"'�0 a.m. Cl p m.(check onel [o�_�'IS Tlme:_.L'a.m. �p.m.(check one) <br /> irom: �mMddlrm) <br /> (mm/ddlYl'VY) <br /> b�5.�pn 5 nn horn �^�'.���k��-�" <br /> 9, LocaUon of Inddent .W]]� p p��rircaG'e Plarn whercoauimd <br /> srareaneraunty �% - - � ' <br /> 10.If lhe Indden[occurred on a stree[or hlghway: <br /> �Q�i y � �S� <br /> /Jume al,f cef a•h'ghrvuy Atlhe/nMrsecf`.�uRh e�nearrrt IntrrsecHng sfinet <br /> Rov.O7I07 <br /> � <br /> � � � <br /> 1 � �� ; <br /> �.'_ � <br />