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Clq•ol Evcroll Uso Only <br /> TORT CLAIM FORM ���E���� <br /> a��.o„o, SEP 11 2Di3 <br /> Pursuant to Cliapter 4.96 nf the Revised Code of VJashingten (RCl'�, C�TY �� �'�E��+�"�, <br /> lhls (arm Is (ar flling a torf dalm agalnst the City of Everelt. Same of , . <br /> the Informalion rcquested on lhis form Is requlred by (iCVJ 4.96.020 „ <br /> and may 6e subject to publlt disdosure. The Clty Clerk Is lhe Qty; cuycm�kc � . �- �. <br /> desiynaled agent (or lhe purpose of re�elv6ig dalms. Clalm forms Q� I[a �I I'� <br /> cannot�esu�mittedelectron/ca!/y(viaa-mallorl.ix)_ (�e_ p�300 y7 <br /> -P.LEASE'T,VP,E'OR�PRINTiCLEARLY,INbINK . ..�'1= + _t..�� . �' r,�: ,,''�' ,�� ,�.����� <br /> Mail or dclivcr original signed claim form to: Office of the City Clark <br /> . City of Evcratt <br /> tSuslness Hours: Z930 Wetnwre Ave.,Ste. 1•A <br /> t•1on.-Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 <br /> Closed on city holidays <br /> CLAiP7ANT INFORMATION: <br /> 1. Clalinant's name: <br /> srEni� r� scb� R�uf�nv o � -� 9 - i97F� : <br /> Lastname Flnt �4rddle D.tfeo/birth(mnr/dd/}yyy) <br /> 2.currentresidenualaddress: _ zZ� 9 �>�"��N �e s-iVv�-roM�f� !.v/�' 9�L9� <br /> 3. Maliln9 address Qf dlffemnt): ____ __ _ <br /> 4. Resldentlal address at the t'mc o(the Incldent(If dllferent from cviTent address): <br /> � �O-� � 'n�� ✓ i �� i A=�rG Z�--l�- - <br /> 3 ��T-t�� �--��""-¢�"*—� t� <br /> S. Cla�mant'stelephonenumbcr: _ yZS ' �zU�9U�9 yzs- ��JS' 6��9 <br /> -. �fanx• Cell ftaslness <br /> G Clalmant's e-mall address: S S T e N G f I� e Y e Y�- f"f' S O� b�_ <br /> �/ <br /> ffVCIDENT INFORMATION: <br /> 7 Dale o(Inddent: � q_/� s x°� 3 Tlme : - _,_�-- I �a.m. }��.m. (cher,k one) <br /> (mm/JJ/yyyy) - <br /> H. ](the Inddrnt o arred over a perlod of:hne,date of(Irst and last occ rren es: �j <br /> fwm:�9��y��� nme:_�Il a.m. T�i.m.(check one) to�9 06�pme: V ❑a•ni.�.m.(check one) <br /> �mnJddll'YYY) ._ (mmlddM/VV) / - ,. <br /> A rr-+��NGr�N SvvoN��M�SN 6�G2�7r <br /> 9. IacaUnnaflncldenL• �✓ � -- �L ---- .. - -- -- <br /> Stvle and munry Qry,lfapp7cable Place ivhem ocn� rireA AV F <br /> . 2V02 /�OY'� <br /> 10. I(the Indden[ocarred on a street or hlghway: EY�ler�� w� <br /> _ �'�A. 9 g' � n I ---- <br /> Name olslreet orh�ghicay At fhe InhrsceUon wlfh ornemest Infersec!ln�s(rce! <br /> Rov.07109 <br /> . . . . . _ .. . . . . . . P.'.�'..J. ,, <br /> . .. . . . ��� -�� .. <br />