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El/ ETT <br />ecv. o�/ov <br />TORT CLAIM FORNI <br />Pursuant to Chapler 4.96 of thc Revised Codc of Washingtnn (RCW), <br />[his form Is (or filing a tort dalm a9alnst the City of Everett. Some oF <br />Uic in(ormaUon mquesled nn this form is reqWred by RCVJ 4.9G.020 <br />and may be subjecY to publlc dlsdosure. l'he Giy Clerk Is the City's <br />deslgtn[ed agent for the purpose of receiviny claims. Gaim fornu <br />cannotGe subnriKed dectronicalty (via e-n�al/ or (axJ. <br />���V��T�n�� <br />SEP 19 2013 <br />6dJiH��� ���L'��Il R <br />Citg C9e�� <br />Ciry Cleih C�i!m No. <br />I)I`��t_ I3 <br />_ _.. , . ..... <br />PLEASE�TYPE OR PRINT CLEARLY�`IN INK -�-'�:- `'" � �= . � � ��� � � � �� <br />Mail or deliver otiginal signed claim torm to: <br />Business Hours: <br />Man. – Frl., 8 a.m. to 5 p.m., PaciflcTime <br />Closed on city holidays <br />CLAIMANT INFORMATION: <br />1. Claimant's name: <br />lrYsf <br />Office oF the Cily Clerk <br />City oF Everett <br />2930 Wetmore Ave., Ste. 1-A <br />Everett, WA 98201 <br />t� <br />�o //9�} � <br />Mrdd'e Dale o(Glrfd (mm/dd/Jyyy) <br />2. Nrren! residen[ial address: _ I�(L 3 QJ� -�i�' �, r� li b_Ll��p_ . k�_ <br />3. Maliin9 address (If dlfferent): <br />4, Residentlal address at the lime of the incident (i( different from current address): <br />S. ClalmanPs tclephone number: _%C7�_�j� �� (oy ��' S��l S-_L1��1 <br />Nane Cell Buslness <br />G.Cialmant'sc-malladdress:.�LF2��?—�IVU�� �� �£/�U 3�i2JGi._C'.�w( __ <br />7NCIDENT INFORMATION: <br />7. Uate of Inddent: �_( �. ���� � 3_ -_ Tlme :._.�-0 r� __ �� a.m. ❑ p.m. (check one) <br />(mm Jd/ryyy) <br />D. If tlie InciQent o:arred over a pedod of time, date of first and last ocarrc� �c�,e�s2: <br />(rom: �r/–� /LplSfime: _�QO_ l>Ia•m• 17 D.m. (checY, one) to _�J/ObJ�,yam^: S_��_ �yia.m. l 1 p.m. (check one) <br />(mmlddlyyyy) (mnf/dA/IHYY) <br />9. Localion oP Inr.ident: <br />10. lf lhe Incidenl occurred on a sUeet or hi9hway: <br />Name o`slme( orhy!r.vay <br />F2ev. 07109 <br />�( <br />City, i!t <br />At (hc /ntc�sedbn <br />Plvtc <br />, �. <br />��/ ��� ,� <br />l:� . <br />