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� Clry al[voretl Uao Only <br /> R�C��V�1� <br /> E TORT CLAIM FORM <br /> nev.m/oa <br /> SEP i'r 2013 <br /> Pursuant to Chapter 4.96 of the Revised Code of Washln9ton (RCW), �jTy OF gVE�t���"�� <br /> this form Is for filing a tort dalm agalnst the(Yry of Everett Some of <br /> the fnforniatlon reques[ed on lhls form Is required by RCW 4.96.07.0 �lfi/ �,'��y;�, <br /> and may be suhject to pu611c disclosure. 'fhe Ciry Clerk Is the Ciry's Ciry L'leik Claim o. <br /> destgnateA agent for Ihe purposc of rccciviny dalms. Cla6n /orms (�1�r'� � I� <br /> cannot be subm/tted electronlca!ly(vla a-ma!l or f.ix). <br /> -- - --- - GCao�3o0`i5o7 <br /> PLEASE;TYPE OR!PRINT CLEARLY ,IN,INK' ' " ''' •: . ' <br /> Dtail or deliver original si9ned claim farnt to: Office of the City Cler{c <br /> Clty of Evorett <br /> Business Hours: 2930 Wetmora Ave.,Ste.l-A <br /> Mon.—Fli.,8 a.m.to 5 p.m., PacificTimo Everett,WA 98201 <br /> Closed on city halidays <br /> CLAIMANTINFORMATION: <br /> 1. Clalmant's name: / j <br /> ���CC •��(__I C (,r!'��//l�(.'� //��f l��7��- <br /> �asnrvmP Pirc! ldrdd/e W�eo/G/�th(mm/.1d/�yyy) <br /> 2.Current resldentlal address: �/I���/ L� i�r�,(-�l�.>� �l/�� �y��%/� l//� ����� r <br /> 3. Malling address Qf diffcrent): ��I-1-r��'i c�'_ __ _ <br /> 4. Hesidential address at the time of l�e inrident(If dilferent from arrent address): <br /> 1'`��.��1 )G K_CS-d��_—C.�.� 't'��-l-.I��1`l i���-"� <br /> 5. Clalmant's telephone numhcr. lI^�_`j.<�� �) l; �.�-���, �����-:���/C '��..�����: 1�J:`�iY(-'.>/ll`J <br /> / Name , Q:q Uuslness <br /> 6. ClalroantS e•mall addiess: _c G7 t�,c'r�-�F' i �.f-�. 1 ICI��i/•,' C�i ir,=.1 <br /> J <br /> INCioEN7IN FO RMATIO N: <br /> r-, <br /> 7. Date of inddent �~I� .����_�____ ilme ; '��'�V�__ LI a.m. ��in. (check one) <br /> (m�Nna/wrv) <br /> 8. If the Inddent oaurred over a period of time, date of first and last occurrences: <br /> fmm: . 71nie:, ._LJ;i.m. f7p.m.(checkone) 10___ 'fime: ,Oa.m. Op.m.(checkone)G� <br /> (mMd�Urvri) C (miiJed/yyyy) I 0�� <br /> 9. LncaUnn nF Incldr.nt: r,/����7��n'11��1 ���Ca Y� I "�1� :1���'!1�t=�J7 � -- �A /J <br /> Sfv(c attd munty City,!/uppl/nblc P/are wheic ocrurrcr/ <br /> 10. If the Indden[occurred on a street or hlghway: , <br /> _L�ilu�SF' ;�� f,�;SF'�,���/1� <br /> Name ds(rtrl wh9hxwy Af h5e Inkrsttfhvr ndth or neamsf inhvsc:G'ng sfrcef <br /> Rov.0TI09 <br /> �\ <br /> 7 <br /> j �-i : <br /> � 1�� , <br />