1615 RAINIER AVE 2022-05-06 - Laserfiche WebLink

REcErvED TORT aArm FORM AUG 3 0 2013 Rev.07/09 CITY OF EVERETT' Pursuant to Chapter 4,96 of the Revised Code of Washington (RCW), CityClerk this form is for filing a tort claim against the City of Everett. Some of the information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim No. designated agent for the purpose of receiving claims. Claim forms y1)0 L g 13 cannot be submitted electronically(via e-mail or fax). • P>LEASE. PE. .P I l:A LY..I K> .:;•. ;�;O T,:'fit'-. .R L R . . .T . . Mail or deliver original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste. 1-A Mon.—Fri.,8 a.m. to 5 p.m.,Pacific Time Everett,WA 98201 Closed on city holidays CLAIMANT INFORMATION: 1. Claimant's name: L_pp .1./A It. f)ttf: Q r wre i e OO•--1S Last name first Middle Date of birth(mm/dd/yyyy) 2. Current residential address: I615 ga.'n,ter Ave. 6ve(e44, i,./A q(f1 ,1 3. Mailing address(if different): .. Ifri e. 46 al) ve. 4. Residential address at the time of the incident(if different from current address): StirnI as at:,i,z , 275 5. Claimant's telephone number: I)25'"773 <S25 t125•--773 $275 t �irime Cell Business 6. Claimant's e-mail address: a tt�rf, ..S,..a1e . d y e r d. Lorr INCIDENT INFORMATION: 7. Date of incident: /'Z /ao 13 Time : l ❑a.m. L1 p.m. (check one) (mm/dd/yyyy) 8. If the incident occurred over a period of time,date of first and last occurrences: from: Time: ❑a.m. ❑p.m.(check one) to Time: 0 a.m. 0 p.m. (check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: VA 5rb1v' h nl L vr'iW (G1_ Ret.n, State and county City,if applicable Place where occurred Res,dmte) 10. If the incident occurred on a street or highway: 164-h ��— and Ra,a.cr Ave- ci 1 7o 1 Name of street or highway At the intersection with or nearest intersecting street Rev.07/09