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�, <br />4 <br />� <br />n <br />I <br />EY ETT <br />nev.o�/o9 <br />TORT CLAIM FORM <br />Pursuan[ to Chapter 4.96 of the Revised Code oF Washln9ron'(RGW), <br />this Porm L^ For flling a tort claim agolnst Uie Ciry uf [verelt. Somc o( <br />the informadon requesled on this form Is required hy RGW 4.96,02D <br />and may 6e subject [o publi� disclosure. 7he Cily Clerk Is the CI[y's <br />deslgna[ed agenf (or the purpose of recelving cl; Ims. Cl�im fvrms <br />uinnut ba sabmlKed elechnnica/ly (vl.� e-mai!or fax). <br />C(ty odl Evarctt Uec Only <br />�� `A.��� V �� <br />oci �:4 20» <br />W..Ak Y �� �d T,�AUI(.i�ll <br />Cfi�y �flc�k <br />Clly CI ik Cinlm No. <br />���I�� ~ 13 <br />�— P_L'EA�ETYPE�OR [t;ryTeC_ A l�[?SNiI N.�,._y" S j�>�;:?:T.;)',..`� .1'.3_�,;: i����,L..;3 ��,,:'._��:��� <br />__ � � �� .. � R_ <br />Mail or deliver oripinal signed cloim form to: <br />Buslness Hours: <br />Mon. — Frl., 8 a.m. to 5 p.m., Pacific Time <br />Closed on city holidays <br />CLAiMANT IN FORMATION: <br />Office oF the City Clork <br />City oP Evercitt <br />2930 Wetmoro Avo., Ste. 1-A <br />Everett, WA 98201 � <br />�� ,.t_� � <br />����,. �= <br />j'�.ti 1 <br />1. Claimaot's name: � � / <br />�'0,8-i17'/!2 'W.�' / /i1022r� i�" <br />�.�c,vl�(' �f; .'..,,��1�,a-� <br />/ <br />Las!— namc~ V r�s[ P!lddle Datc a/Gid/i (mm/JJ/y�ryryJ <br />2.Currentresidentialaddress: IU(),} /'OG►� /i/, �/f�G�'— l7,F�' t/� ���;'%%J <br />3. Malling address (IF dl(ferent): !V �•�s� K i'� �" y G�f�"7�r �7 �Z� G� <br />i <br />4. Residenlial addmss at lhc lime of lhe incident (IF ci ffcrent from cwrent address): <br />�i- <br />5. ClaimanCs telephone number: <br />fi. ClaimanPs e•mall address: <br />INCIDENTINPORMATION: <br />�1,OG °/��• �qg! 1 <br />llane Cdl J lJus/ncss <br />%. Uate af incldent: �/� ��'��� � 'ilme : LI a.m. �] p.m. (chede one) <br />(min/dJ/V17Y) f <br />ll. If tha IncldenC occurred over a perlad of lime, dale of IIrsL and IasC accuircnas: <br />fmm: 'I Ime: ❑ a.m. CI p.m. (check one) to Time: _._ CI a.m. LJ p.m. (chedc ane) <br />(mm(dd/YYYV) immlJdIYYVY) <br />IOQ �— <br />I. Lowllon of incident: � nn�0 n/. NllaA.�. ./� f� . lE7�S..�i� i`` �i/At/ q S�2A / <br />lU. If lhe Incidenl ocom ed on a street or high�ti�ay: <br />4ty, l(appliovL/r. Pl,�ce <br />h'ame ofshrrf nrh!qlnvuy Af Ne lnlrrsrdian �vdA or nnimct ln(rrstt(ing s(rref <br />Rnv.07109 <br />