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Rev.07/09 <br />TORT e'LAII�I FORM <br />Pursuant ta Chap[er 4.9G of the Revised Code of Washington (RCW), <br />this form is for filing a tort dalm against tiie Gty of Everett. Some oF <br />ihe informatlon reques[ed on this form Is myulred by RCW 4.96.020 <br />and may be subjed to public disclosure. The City Clerk Is Ihe Gty's <br />designated agent for tlie purpose oF receiving clalms. Claim lonns <br />tanno[ be suGmitted electronlca/ly (vla e-ma!/ar fvx). <br />City ol Evemll Uso Only <br />1\���� 4 �A�/ <br />AUG 3 0 2nti? <br />CITY OF EVE�iE'I'T <br />CilyCle.ic I � �►!--A�.� <br />_l�ntoy-i3 <br />_. .. . _ _ ; : , <br />.PLEASE 7YPE OR:PR[NT CLEARLY IN3NK _ . _. , . . '_ . `• .._ _:. �... __.. ; . ! <br />Mail ordelivcroriginal signed claim form to: <br />Business Hours: <br />Man, — Fri., 8 a.m, to 5 p.m., PacificTime <br />Closed on city holidays <br />CLAIMANT INFORMATION: <br />Office of the City Clerk <br />City of Evorett <br />2930 Wetmore Ave., Ste. 1-A <br />Everett, WA 98201 <br />1. Clalmant's name: <br />���#-[,� � � �✓ b�iL� I.�h-✓1 V✓ ::��8 �/�i �C> <br />[ast name Firsf Alyddlc Dafc ofG/Rh (mnr/dd/yyyy) <br />2. Current residential address: l� U> /(� �'��l l� I L� C� �� ���� l d��`nLf% ��%jGU..7 <br />3. Nailing address (If different): <br />4. Resldential address at the timc of the inddent (If different From arrent address): <br />5. Uaimant's telephonc numher: �% S`�17_ ��! lZ'� 7UG� 7 7 1 kLu` �� �1 ti�`�0 �� ��1 <br />Ffame � , '/ lc/I Basfiresr <br />6. Galman['s e-mail address: _l�� �— �-f,A'�' L�-`�� �' � � v r� r��+ i� • e �»-r _ <br />INCIDENTINFORMATION: <br />i. Date of Incident• 2-" ,'�''L!) / i <br />(mmJ d yyyy) <br />Time : <br />8. if the Incldent occurred over a perlod of tlme, date of fir�t and las[ aavrenms: <br />from: Time: ❑ a.m. [] p.m. ;check one) lo Timc <br />(mm/dd/yyyy) (mm/dd/yyyy) <br />9. �ocaBon of inddent: S,vn l'It7it'� � S' << U, I.V /1 <br />SfaMar,drounfy G4: <br />10. if tlie inddent oe�urred on a street or hlghway: <br />❑ a.m. .�p.m. (check one) <br />❑ a.m. ❑ p.m. (chttk anc) <br />����)'� r.� m �, i� �c: n,= ���. ,,, <br />Plam n�hcrt acumd <br />Numeafs+mef orhighway Allhe /nfeorcUan wilh a nmres!lnArsec(rngsbeet <br />Rav. 07f09 <br />\I� '�� <br />� -- <br />