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� <br />�� <br />Ti�RT d:LAIly1 �ORM <br />1!ev.07/09 <br />Pursuant co Chapter 9.96 of the Recised Code of 1Nashington (RCVJ), <br />this form Is (or filing a tort daim against the City of Evcrett. Some of <br />the in(ormation reques[cd or, Ihis (orm Is requLed by RCtV 4.96.02U <br />and may be subject lo publlc disdosure. The City Clerk is thc City's <br />Cesignated agent for the purposr. o( receiving dalms. Cla1m (o�nrs <br />canno! be submiKed electronically (via e-mail or faxJ. <br />�.PLEASE TYNE-6R,PRINT, CCEARLY`.IN INK � � '_. _, <br />t•tail or deliver original signed elaim form to: <br />Business Hours: <br />Mon. - Fri., 8 a.m. l0 5 p.m., Pacific Time <br />Closed on dty holidays <br />CLAIMANTINFORMATION: <br />1. Claimants name: , <br />L.a,Y name <br />2. Curren[ residential 2ddres,: <br />���.���i�� <br />, <br />SEP r� ; 2�1'3 <br />C�TY OF EVE�tE�'�' <br />ci�► cl��� <br />CIIy Qe�Y. Clalm `Jo. <br />�—ici i >l "— I 3 <br />Officc of the City Clerk <br />City of Everett <br />2930 Wetmore Ave., Ste. 1-A <br />Everett, WA 98Z01 <br />��5( <br />E'1% �a�`� <br />TI <br />hllddle <br />IJ <br />3. hlalling address (if diRercrt): — <br />4. Residential address at fhe lime of the inciden[ (If di(ferent from current address): <br />�� <br />� `� -- �v ��t,� � j � —� -�— . <br />5. Qaiman['s ce�ephone number. -S�•n E' � f � ( cr�-- � � `- C I � I �I") `� J � � - % �� <br />Honiet � Ccl! Ousiness <br />G. ClalmanCs c-mall address: >'G� U c_Ll.�`}(���1_I.l �ll (.t D �.!'..i� 1"T'L.- _._ - <br />--�- <br />INCIDENT INFORM_Tl� ION: <br />7.Dateofinddent _ ��� "���I_�-3 __.— ���������'�� r� ��a.m.�p.m. (<heckone) <br />�immldAl11NY1 <br />A. If the InclAent occurred over a period of Cime, date of first and last oca�rences: <br />from: __— fime: ❑ a.m. L7 p.rn• (check one) lo ___. Tlme: _ .17 a.m. I I p.m. (check one) <br />(mMddlm'Y) (mm/dd/rvW) <br />\�,' � y [" ^ ' I I I � <br />9. Lootlon of Incident: '+" �` �' r1�c}--{—Ci1�1 - � V C'_;�-C �'� �•.� �I � }-j[I �/)—�- --v f � <br />Shfe and rounly City; ifapplrtab,�e Hace where udcc RN --- <br />10. If the Incident occurred on a street or IVgh�vay: <br />A'ane o/sfnrt n�LV7`w��Y A! th^ in!evSrJ.n �5i(h cr n�rest li!.'aseclln9 s6er.t <br />� <br />P.et OilO? y I <br />y 1 <br />�/% C'- ) <br />