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Ev Err <br />TORT CtAIM �ORM <br />�u!suant to Chapter 4.96 of the Revised Code of Washinglon (RCW), <br />this form is for �ling a tort daim against the City of Everell. Soroe of <br />the information reque,led on thL form Is required by RCW 4.96.020 <br />and may L'c subjed to public disdosure. lhe Gty Cleik Is the Oty's <br />Gesgnatetl agent for the purpose of receiving d'alms. Claim �ornrs <br />cannnt be suGn�itted elecfronical/y (via e-mail �r (.�xJ. <br />�PLEASETiYPE�OR�PRINT�CL�EARLY'•IN INM .�, _ _ _ .. <br />Mail or deliver originil si9ned claim tonn to: <br />6usiness Hours: <br />Pton. — Fri., 8 a,m. to 5 p.m., PacificTime <br />Closed on city holidays <br />CLAIMANT INFORMATION: <br />1, �lalmanl's name: <br />S�n�s ( <br />[asf nam� <br />2. Curren[ residential address: <br />3. Mailing address (if differenl): <br />JAN 13 20i4 <br />Ci'�'1 �F E�1FIZET�' <br />�ity ��c�.��;. <br />Cily C^lerk qaim No. <br />1/�^Q� — �.� <br />Office of thc City Clcrk <br />City of Everett � <br />2930 VJ�tmore Ave., Ste. 1-A <br />Fverelt, WA 98201 <br />Cf. ✓('l,elY'% <br />fvst -- <br />' YI. •..,�. ' <br />� '�. ?!.• . . . . . .. . . <br />11-�8-1���� <br />DafeI o/birth (mm/dd/yyy� j <br />�SVi CL.'�Y� �)�o�C� <br />4. Residential address al the time o( the Ircident (if diffemnt (rom current address): <br />_ ��o� Y�Iu�� ��.. �,zF1��_��,r�- ����C>I <br />�� /; l <br />5. Claimant'S telephone numhr.r. _�"'�'���'�L�11±������1L`� �I`�'��7� 3�� ��n� __ <br />Nome � Crll fiusiness <br />l;. Cla��manl':; e-mail adrLess: . - <br />INCIDENTINFORMATION: <br />i. Dale oi inciAenl: _���� �-L�� __ <br />cmm�fi,/rvn•) <br />P. I( the incident occurred over a period of lime, date of first and last occurrences: <br />(i�ip; Tlmc: __ __ � a.m. U p.m. (check onc) to Tlmc: <br />(min/JA/V)'W) imnddd/YYYY) I�, <br />9.I.ocationoflncident: LU✓�1� ��'l(�I�('�' S�!�•`�i_—��i�C.'rl <br />?0. If the incident ocarred on a street ar highway: <br />�a.m. ❑p.m. (checkanc) <br />«� <br />❑ a.m. ❑ p.m. (checY, one) <br />Nanrc o/s!icct ,� hl�,hiray Af (hP m:e'sei/or, n:U� n� maieif infe6e[h):g sfnee; <br />