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_ _�d.d�o�`� V �� <br /> Ev rr TORT CL,4Ii►9 FORM SEP 10 2013 <br /> R�,-.o,i�� ry+!� <br /> Pursuanl [o Chaptcr 4.96 0(Ihe Revlsed Codc of Washinglon (flCVJ), �IA 1 �r'�tl p���'I' <br /> th!s faim Is(or Olin9 a tort dalm against Ihe Cdy o/Evcrett. Some of !'V <br /> Ihe hiformatlon requested on lhL (nnn Is mqulred hy RCUJ 496.020 �"`� ��tS� <br /> ariJ LI.IY IIL' Sll�)P.CI IO �IDbUC d15CID501C. TI1F City Cierl; Is lhc Qrys ���v�i��kaxon�o. <br /> deslgnatctl agent for the purpose of rcccivinp dalms. Cln/n� Jarms - <br /> cannot be suLrnlfteAe%cfroiilcalty(vla e-mallarf.�xJ. .� <br /> - -- --- _ao�30o y 5 <br /> PLEASBTYPEORPR1Ni�CLEARLX�IN�INK �.. - . �.:- • . � .. . . � . .. . . _. . �. . . <br /> Mall m•deliver ori9lnal slgned clalm farm to: Offica af tlio City Cledc <br /> Clty of Everatt <br /> Buslness Hours: 2930 Wctmm'c Ava,Ste,2-A <br /> t•ion.—Frl.,8 a.�u. to 5 p.m.,Pact(ic 7ima Evci�ett�WA 90201 <br /> Ciosed on dty holldays <br /> CLNMANT 7NFORMATION: <br /> l.c'JalmanCsname: Coc� — oi�11�19S1� <br /> ..;illr and �� t}1 f25(I°j4�0 <br /> —IjPf clll S Lef� <br /> Lasf n�nm fl�sf A;lddle Datc otbfrih(mMdd/Y�7Y) <br /> 2.Current residcnllal adAress: �_S E��y - A``� _ <br /> 3. I-0zlling address Qf Alffcrenl): _ . ___ <br /> 4.Rrsidentlal address at Ihe Ume nf the Inddent(If dl(ferent(rom current address): <br /> [a�li W�� <br /> � a� 25?-2� 2(� 25•24,g-3'327`� y_LS•21�8�?:�89 �•n <br /> 5.Clalmant's telephonr.mimlier. _.(--' _-�-- J_ ---- �- -� <br /> Nome Crll ��ulne.0 <br /> G.Clalinant'sc�mailatldres;: ��n^�•,�r�C�r�.virm{:n��-�'- d �sc.�ll[1c�.,,�cu+;l. nc!' <br /> INCi E T INFORh1�Ti0N: <br /> 7.Date of�nddr.nr. `d 1 " -('_'-_f�([�3 iune: _ __. [7 a.m, M 9.m. (check one) <br /> (mmJdd/ryryj <br /> e. If lhe Inddenl occurred over a peilod of lime,dale of lirst and last occurrences: <br /> Gnin:___ Tlmc_ _(]n.in. fl p.m.(check one) lo__Tlme:__ ____0 a.m. O p.m.(check one) <br /> (mmldd/yyyy) (mm/ddlYlYV) <br /> 9.lcicdllo0o(I�Clden[: W� r�o�tlh+�������—_—_CJLYI'��{- ISIS F��`=�aSc;y�y�r <br /> SG�dmun!y O�(Y.IL�ppS?ahle f/.�cewlrerto¢mrtN <br /> I0. If lhe Inddent occurred on a slreet or hlphway: <br /> �h— -- — _— <br /> Namc r,/sNre!m h.'gA�ray Af fhe,nfcner!!nn n�Rfr wnearest l�'�nrcN rg slmef <br /> Pov.07109 <br /> 1 <br /> �/ `� <br />