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i <br />Ev rr <br />TORT CIAIr'N �'ORM <br />A�,. �,io� <br />pursu•nl to Chapl�i� 4.95 oF ihr. Revlsed Code of VJashington (RCV:), <br />thls (o�m is f'or Nin� a lntt clalm a9alnst tLe Gty oF Evere[t. Some of <br />the InfarmaUon r��ucsted on thls form I; rcqulred 6y RCVd 4,g6.OZU <br />antl may be subject fo pu611c Al�dosure. The Cily Cierk Is Uie Clty's <br />dcsignatzd agent for the pwpose of rcceiving dalms. Cl�lm fonns <br />cannotGesubmlYed e%clronically(via e-:nail orfax). <br />Clry oI Evc•ofl Uso Oniy <br />GIIy Clerk Clalm t:o. <br />;PL'FAS��T�'�E19��.�gIidT1�.F�.�Ea.��� �FN I!J�i� i � .. �. _ �...v:�i�'� L. ' 1 �l';'�:', ..0 .., �:rC.. _ �., �.`. � � � .1 �.'. );I <br />P1ail or deliver ori9inal slgned clatm fomi tc: <br />Rusiness Hours: � <br />�-0on.- Fti., B a.m. to 5 p.m., PaclficTimo <br />Closed on clty liolidays <br />CI.AIMANTINfORMATION: <br />Of(ico oF Yi�a City Cleric � <br />City of Evcratt <br />2930 Wetmoro Ave., Sta. 1-A <br />Evcratt,LVA 96201 <br />1. C!aimant's namr. <br />��� � va c1.1,� � ��_r��6� <br />� ` Fi�r r�✓dr� oa[eo hGth(mn/dd/yyyy) <br />Lastname q <br />�( ` ��� � <br />2.Currentresidentlaladdmss: _L�� 1 �� � — '����-P• N�- hia�'(ISJ r��t' . �i � <br />� <br />3. id�lling address Qf dlfferen[): <br />4. Resldentlal address at the tlme of the Incldmt pf different Gom current adJiess): <br />�-���iqFi �f.a� �-G(.�( Y� 1' <br />ti, Clalmant's leleplione number: ��� E�-� _. _,— �-� �3 L_ __-- 5 3 `� �J � % % J <br />Nonrr C�ll Ru�ncso� <br />r,. Clalmant'se-malladdress: _ � r��'�`-rl-(��n�1-�l . . GQI'Y1---- - <br />,-- - �J <br />INCIDFNT IIVFORMATION: <br />7. Dale of Inddent: �ij�� ��J_� .__ Timr.: ltt-{"(.1' � ❑ �.m. �p.m. (check one) <br />(mm/dJ/V1YY) <br />N. If the Incident occurred over a perlod of lime, date of first and last occwrence;: <br />Gom:--_----l1mr.-- —Oa.in. flp.m.(ch�cY,onej to..--_-Time:-__-.--Oa.m.11p,m.(checkone) <br />QnMdilYVVY) cs (mMdd1VYVY) / n <br />9. LocaUonoflncidenL• W �-~�i �L "Ch'l k%V ?�f-Q'��__._ VoZJ� �D �]-!� T1 `!L <br />Shfe and mtm! L7ry: ffapplkab,�e Placr K�here�ccvm� <br />lo, If lhe Inddent occurred on a street or hlghvray: <br />- � I✓ameofstrectorh/jh�vay /�t!/+�iulcrscctlanw!(hmikvrtnfintrsrctinJsUcef <br />ROv.OTNJ <br />�//'� %�`�••� <br />\ <br />