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Gily ol Evorall Uce Oniy <br /> RECEIV.�� <br /> TORT CLAII�?FORM <br /> �«�.a�ro9 <br /> SEP 13 7.D13 <br /> Pursuant to Chapter 4.96 0( Ihe ReviseA Catle af Washington (RCW), C����i �i'� a <br /> thls form Is for Olfng a tort dalm agalnst the City of Everelt. Some of ����+� <br /> the InformaUon requestetl on Ihls form is reqWred by RCW 4.96.0?0 <br /> and may be subJect to publlc disclosure. The City Clerk Is the CIty's ClryCleikCloimN . c� <br /> deslgnated agent for the purpose of receiving dalms. C/aim lorms � ` 3 I � +� <br /> cannn!be submitted elecbon/ca/ly(viT e-mailorfaxJ. <br /> -- o no 44&9 <br /> pCEA5ET1(PE�ORPRINT�CREARLV� iNINK�`�r . . . , ' ' .. . .`'•��' , ,. . . . <br /> Mafl or deliver arigtnal signed cleim farm to: O�ce of the City Clerk <br /> City of Everett <br /> Business Hours; 2930 Wetmore Ave.,Ste.1-A <br /> Mon.—F�I.,8 a.m.ta 5 p.m.,PaclflcTimo Ev¢rett,WA 98201 <br /> Closed on city holidays <br /> CUIIMANT INFORMATlON; <br /> L Clalmant's name: <br /> L_l.lrS�v� �.rib'�c��a.� � ��8�19(a(a <br /> Last namc Firsl l�;ldd/e Ll�fe ofb/rth(mm/dd/yyyy) <br /> 2.Currentresldentlaladdress: �ig21 IZ��e,7novt ���v�'rN�_In1� 9gZo� <br /> 3.14alling addiess(If dlKerent): ' <br /> A,Resldcnlial address at the Ume of Ihe Inddent QF dlf(ercnt from current address): <br /> S.Claimant'stelephononumber. �125-z'�V-O�5} <br /> Name Cr!l 6uslness <br /> 6.ClalmanPs c-mail addmss: ���s�ti�ac�cz.c��.....�.yp.,n�-� <br /> INCI4ENTINFORMATION: <br /> 24 <br /> ?.Dale of Incident ,� mR `i4 1.3 71me: Co'bo �]a.m, fi�p.m. (check one) <br /> (mm)dd/yryy) <br /> li.lf the Inddent occurred over a perlod o(Ume,date of first and last occurrences <br /> frnnc Time: ❑a.m. IJ p.m,(rhr�.k one) lo Tline:_._CI a.m. G p.m.(check one) <br /> (mm(dNypy) (mnydd/yyyy) <br /> 9.Locatlonoflncldent: w� �Ho�a�.;�, �vw�r�k1— 1i521 R�J'ya,...�.,,�t D, <br /> S1aM and rounty O�ty,l/a0P•'��bk Plare when+attvrrcd <br /> IO.If the Incident occvrred on a street ar hlghway: <br /> hnnmolsfrtYfah/ghway Atfhe/nluseMoinWtliorn�ncst/nknertlngshert . <br /> Rav.07109 <br /> � � <br />