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TORT CLAIM FORM <br />Pov.07/09 <br />Pm'suant ro Giap[er 4.96 of tho Revlsed Code of Washlnc�ton (RGW), <br />lhls form Is for Iiling a toit ctalm agalnst the Clry of Everett, Some of <br />tho informatlon requested on thls form Is requlred by RCW 4.96,020 <br />ond may be subJed to putllc dlsclos�ire. ihe Ciry Clerl< Is Ihe Clty's <br />desl9nated agent for tho purposa of receloing clalms. C/alrn lorms <br />eennatGa subnrlKad elect�nn/cally (v/a a•ma// or /axJ. <br />������� <br />SEP 0 6 2013 <br />CITY ON EVBItETT <br />��� C�� <br />ly C!o�k Clalm No. <br />�11�t1.- I� <br />�' f !- y �.Y�. �J .1l\>>��� � �il �:i'`I��`� � ���1l�J�tilyttiqt�\\('�. xC A('i <br />i1�lEA`Sk`,1�1;�'�I4"N;�'.d1j�I�'�:G��.AJiRU1',i'�Yt7,XN1� ,�. . ,..�., :, icne,,. . ,..,� , .._ ,. �.,,. ,,.� � . .,.:.,: <br />Mall or dollver orlginal slgned cialm fornt to: <br />Bustness Hours: <br />Mon. — Fri,, 8 a.m, ta 6 p.m., Paci(Ic Time <br />Closed on city holldays <br />f.LAIMANT INFORMqTION; <br />1. Clalmant's name: <br />ornca or cho ciry aerk <br />Clty of Everett <br />2930 Wetmoro Ave,, Ste, i-A <br />Evcrott, WA 98201 <br />`�, <NA-cA �� A�rt�G��, �s���_ �— �� -Co � <br />tastn.�nrc Flnt Id/dd/e 1 pnatcoleAth(mnt/dd�yyy) <br />2, Current resldcntial address: _��57 �ti���A'�k + )R • ��/, �✓'A, /Q�� <br />3. Malling adtlress (IFdllferent): <br />4. Resldentlal address at the tlme of the Incldent Q( dlfferent from current Address): <br />ti. CWlmant's tclephone numher: <br />G. Clalmant's e•mall addres,: <br />DiS�odcco oa <br />7, Date of IncldenL• `�• 3U' I S __ <br />(mm/de/riY✓) <br />2c-33�•I�L� �•3��-31`rl <br />„ LYrI U�slncss <br />'nme: 11:a� ❑a.m. L9'p.m. (checkone) <br />O. If the Incldent occurmd over � perlod of llinq [lale o( Or,t and la,l acwrrences: � l WL- IJ�E O oT 0 r 1 �w�.l, <br />frmn: Tlme: ❑ a.m. 0 P.m. (check one) lo ___ Tlme: � [7 o.m. � p.m. (check one) <br />(mm/dd/yyyy) <br />9, Locallon of Incident: <br />�0: <br />l0, lf tlic Intltlent accurrd on a strcet or hlphway: <br />ROV.07108 <br />(mm/dJJyyry) <br />