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i ' <br /> , `� IEre� �l f ,I <br /> � I <br /> n TORT C,GAIM FORI►� SEP i � 20�3 <br /> Pev.07(09 C,�TY�F EVEI�ETT <br /> Pwsuant ro Chaptcr 4.96 of the Revlsed Code af 6Yash!n9ton (RCVV), Clty �..lE.`L'�i: <br /> thls form Is Ior filing a tort dalm aqalnst the City of EveretL Some of <br /> Uic InfonnaUon requested on this form Is requlrcd by RCW 4.96.020 <br /> and may be subJed lo publlc dlsclosure. The �Ity Clerk Is lhe City's CIIyGmkCla'mNo. <br /> deslgnated agen[ for the purpose ot rernlving dalms. C/almlorms �-�� ����-- - i3 <br /> cannotbesubmlKedeleclronica/ty(vi�e-mal/or/axJ. _ �� DyS�.�- <br /> O <br /> PLEASE:TYPEOR'PRINTiCLEARLY.IN+INK � • <br /> Mall or dellver orlglnal signed claim form to: Offlce of the Clty Clerk <br /> City of Evcrett i <br /> Buslness Hours: 2930 Wetmore Ave.,Ste. 1-A <br /> tdon.-Frl.,8 a.m.to 5 p.m.,PacHlc Time Everett,WA 98201 ! <br /> Closed on city holidays <br /> CLAIMANT INFORMATION: <br /> 1. lalmant's namc: <br /> eee r� �m� l-e� Da� 3 19 � <br /> Casl nvme /� fl�— � M.hi0/e LUR o/b/rth(mrrydQ/�yyyJ <br /> 2.Current resldential address: _ Ibl�� �IA.(-.CSo��( _��1�Q�� Tl 1,� "I a�-V l <br /> 3. htalling address(If dlfferent): � <br /> A. ReslAentlal address al the time of thc inddent(If di(ferent from current addressj: <br /> 5. C`almanl'�S tdephone rumber: � �a5 ', � _ <br /> /� I ome Cell,� /�A y� Buslness <br /> G ClalmanPs c•mail address: _�{; AmQ,�( ' l -U�' I— <br /> J � <br /> ZNCIDEN7INFORMATfON: �� . <br /> 7. Dale of Inddenh �� � Tlme: �_.�, ❑a.m. p.m. (check one) <br /> (nun/Od/yyyy) <br /> 8. If lhe Incident omured over a pedod of Ume,date of Brst and last occurrences: <br /> from:__ Tlme: ❑a.m. O D.m.(check one) to Time: ❑a.m. (1 p.m.(check one) <br /> (mMdNmv1 I� l�,le% � ti:/ <br /> 9. Locatlon of InddenL ���u-i���^Vl�rv-�rul� � <br /> Sfafe and munry Gty,//vpplicab/e oMm whe�e nceum.�d <br /> 10, If the Inddenl occuned an a street or highway: <br /> Name alsfrzrf orhlpfivay Al tlreln(eaecTivn iNfh a mvmst Infasrcf�ng sfrt�et <br /> ftov.07108 \ <br /> ' V <br /> I � <br /> ) ,��� i/ <br /> I • � { <br /> i ff� <br /> '•�� <br />