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�'ORT CLAIM FORM <br />ao,. w/os <br />� <br />Fursuant to Chapter 4.56 oi the Revlsed Codc of VJashington (RCW), <br />t,iis (o�m Is for filinq a tort daim agalnsl the Ciry of Everelt. Srme of <br />the InformaPon reGucsh�d un Ihls fonn is reGWted by RCW 496.G20 <br />and may be subJect to public dlsdosure. The Cily Clerk Is lhe Cit�s <br />dr.si9na[ed aycnt for tho puqmsc of receiving dalms. U.�in� (onns <br />cannot Ger submifted r.leelronlealty (v1a e-nrai/ er f.�x). <br />�y;o �.�� u:Pa�+r- ; � <br />������ � ��� <br />�..'�7P� �F $`�1Ec°�eL`I'7' <br />C�fq C1CTk <br />Clly Clcik Qaim No. <br />1�;�UI - I� _ <br />--- - ;�f:"? r;'�: :. ,:- � .,;:.. � .�..,_ , �;<'.: <br />:PLEASE jYPEtQR:PRINTtCLE4RtiY.T�IN INK .. .; . ,, .: . . � , , . . .� . . . , ^^ �''- . <br />tdail ar delWer original signed claim form to: <br />eusiness Hours: <br />Mon. - Fri., 8 a.m. to 5 p.m., PaciQcT(me <br />Closed an city halidays <br />CLAIMANTINFORMATION: <br />1. Clalmant's name: „ <br />[asf name <br />ORice of the City Clerk <br />Clty oi Evcrott <br />293U Wotmore Ave., Ste. 1-A <br />Evcrelt, VfA 96201 <br />/Olti� �.J��( k^C�-� <br />PI/Ad�e DateofGldh(mm/dA/yyyy) <br />2. Current resldentlal address: °� Sl �—/�1L�% �i V�_— .-- <br />3. �+lallin9 address (i(dlfferentl: _a�{i�J _�C� /}�:..-5�— L'_ 1��-�Gf�� lt�.� ,l�'c�r�� J <br />M1. Residential address al the tine of the Incldent Qf differen[ from currenC address): <br />S. ClalmanCs fclephane numl�er: — - ,-- --- - _ -- --�- - — —7 `�-S - � �' �D// <br />p� Home Ce:l 9aslnczr <br />G. Claimant's c-mall address�. _y:r,;��'.,j�1�-�_4L��—��f �.,,-=-�'`--f{�----�-- --- <br />0 <br />INCIDENT INFORZlQ�O l,: <br />�' G _ <br />7. Datc of incident: _ _ .� ' �_i.. .� , _ . <br />������Jea/nw) <br />Time : 1�,��j _. Ll a.m. (�!I p.m. (check one) <br />H. If lhe Inddent ocewreel ovcr u period af time, da[e of (irst aod lisl accurrenres: <br />Gom:.---Tlmc LJa.ni. ❑p.m.(checkone) to--- .-71me:__U;i.m. ❑p.in.(d�crkune) <br />(mm/Jdlriri) (mm/An/y�yy) <br />9. Localion of InddenL• �ii,/} �i��l_1_t 0 fU C% (/C-.p=G`�i� _ _ ����C) `�- - �T A}��-- `� �- <br />S7alc JnAcounfy .) LIQ: !/aPPliCJblC Pla.�• �S�Actr nraurcv;/ <br />10. lf lhe inddcnt ucmrred on a street or hlghway: <br />__ lAnt<'o/SNrte�NgArcdl' ___" . __ '_ — — Aflh�vak'scN:;nu:flranr.nrsNrlFvsllla9.fmd <br />Rcv. 07109 <br />