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A S� a.i��l 7 �Ai ^ . <br /> Ev rr Tl?61"" C�.A.INf FQKI°� SFP o 5 2013 , <br /> p�, ��,�� C,ETI�' �F E`JEIZETT <br /> Pws iant lo C!:apter 4AG of ;ne Revised Code of 11'asl;ington (RCVJ;, I e�3sr C��� <br /> chi> for n is `or flinn � tort daim against th� Gty of EveieiL Some of `� <br /> the Information rec,uested on this form is required by RCIN 4.96A2i. _ � <br /> anci may bz subjee 10 puhfc disdosure. The City Cl�r4 Is the City's ���y��^fOC,a��,ho. I <br /> Ceslgnated a;en[ for :he purpnsr. of receiving daims. C/.�im lornrs T� C��C� - (��� I <br /> _cannot be submitted e%ctr�aicall}�(vla e-mai/or fax)_ � ` -I ; <br /> - I <br /> i <br /> PLEASE TYPE OR PRINT CLEl1R�.Y TN INK <br /> M19ai1 or deliver original signed cWim form to: Ofiice of the Ci.y Clerk ', <br /> City nf Evcretk ��, <br /> Rusiness Hours: 2930 Wetmore Ave., Ste. 1-A � <br /> Mon.- Pri., 8 a.m. to 5 p.m., Padfic Time Everett WA 98201 � <br /> Closed on city holidays �� <br /> CLAIMANT INFORh1ATI0N: ; <br /> L UaimanYs name: , - � / / ' <br /> �� ` � ' ��'f'> �� Z� /L� /�/ �. <br /> � j�(�� �' .�,1.(. ��':� - - � 1 - �� � <br /> Cast;;eme /�irsf � Aiit/Jle_ Ua2ofblRh(a;m/dd/y}ry�) ; <br /> -� � /J !.- S/ S � �rj , ,�� Gi'. , <br /> L Current residen6al address: _i/J/'(_--�_ / `" � " "�L����������'���- ��r(�� <br /> �- -------- <br /> 1 , . ,�� � � <br /> 3. I tailing address(if differen[): ^ � �� _J_�---- — ---- --- ' ��� <br /> 9. Reslder.tial address at the thnc cf the��i�ident Qf.iifferent from r.urrenf aduress): <br /> � - 1 ll,l ���l(.�. " / .. ._ . i <br /> r '�(��t _ �iT / `����/1:'�'1��)�� l/�.S ��J/ /�(/ �Nr -- <br /> ,. C]�iimant's tclephane number: L _C_(_ -`!___ �V .l <br /> �/�� l♦omc., c!I i lJusiness <br /> .,. ClaimanCs rmail.�dA.rss: ' l'll'%('.'��f�>GL<./ ��,�� �C�(.��'J���:2:1��-' /�'��_ _ _ <br /> i <br /> YNCIDENI'INFORMATION: I <br /> I Date of�ncident: __. - -- Tme : -- __-.- ��a.m. !� pen. (check one) <br /> (mm(dd/yyyyl <br /> tt. If lhe incslanlg curred over a pefiod of lirnr, date of firsf and last,oxurrencqs: 7 .� <br /> (rom: �5�� ��ime: �,S_.f�a.in. 0 p.m.(citeck one) lo�/`�(�5(Jf�,l Tlmr.: / �S .CJ\�.m. ❑p.in.(d-�isk one) �i <br /> (mm/JA/�^ r // Onmldd/Y1'ri,� { � 1� �'1� <br /> '� '1 �) -�x ��i1�.��C�r<.�� '���-,� , C ,�,�°-�<�.-- ��� L�yr1)� C7���.- �� <br /> 9. Locat�noflncident: �-�� �i l"_--_--- -�----- - -- - ---- <br /> Sfalea�counf�• City, i/applicab,�e Pl�mnaSereocairrar! I <br /> 10. If the incident ocarred on a stree[or hlgh�^�ay: � <br /> I�'� -- j <br /> Ndmro(s(�refo'h'Ohn'.3)' � A!f5ain(ersecG'an��nlhornearesNrtoersedaigs7ree! <br /> Rev.07109 <br />