Laserfiche WebLink
Clly o(Evereq Uae Only <br /> ���1� ���� <br /> TORT CL4IM FORM Z`������ �0 n,��'� <br /> Rev.W/�9 E�QZ s o d3S <br /> Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), <br /> this form Is for filing a tort clalm against the City of Everett. Some of �� <br /> the information requested on this form is requlred by RCW 4.96.020 <br /> and may be subJect to public disdosure. The City Clerk Is the Clry', a i i � . <br /> designated agent for the purpose of reteiving claims. Gaim forms �l01�. ' 2 <br /> cannof be submitted elr.cbonica!/y(vla e-mai/o�Tax). � �� <br /> �rC��300 �!!o� <br /> PLEASE.7YPE OR PRINTi:CLEA1ll:Y IN INR <br /> Mail or deliver originai signed claim form ta: Office of the City Clerk <br /> Clty of'Everek <br /> Buslness Hours: 2930 Wetmore Ave.,Ste. 1-A <br /> Mon.-Fri.,8 a.m.ta 5 p.m.,Paciflc Time Fverett,WA 98201 <br /> Closed on city holidays <br /> CLAIMANT INFORMATION: <br /> 1. Claimant's name: / <br /> CC�M.E�1-Ul� Sy��rA' o f( —o2�— ��{,(o'i <br /> lasiname First Mrddle Dateofbirtli(mm/dd�yyyy) <br /> z. eurrentresidentialaddress: �'v�'� ��vLI�EFE�►-�� A-�� � � E�E�E� qBad I <br /> 3. Mailing address(If dlf�erent): �/'��""' _ <br /> 9. Resid�en,�ti^al address at the tlme of the indden[(if diRerent(rom arrent address): <br /> �-1"�U <br /> 5. Clalmant's telephone number:`���✓�a��l� ,a�' "[a-5���'�-$ 6a� _�/� <br /> lfame Ce!l , tlusines <br /> 6.C.IalmanPs e-mail address _. �i� I v� �-C����i L� �o���u� I + �!� <br /> �----- <br /> INCIDENTINFORMATION: b�l���t% ���'A1� E�E1�T" ��i'�7T%NL$N� rLC�l��� �� <br /> 7. Date of Inddent _��� r�U 1 � Time : �� � + ❑a.m. �p.m. (check one) <br /> (��RJ�1lYYYY) � <br /> B.If the Inddent occurred over a pedod of lfm�cp, date of first and las[otturren �J <br /> fmm:$__ .�vi�Time;�_CI a.m. q�p.m.(chetk one) to$�2� �� .ime:�CJ a.m. Uip.m.(check one) <br /> (m�V d� � (mnV dlYYYY) �, <br /> s, �ocation ot Incidenr ___�R"1 M A'N�T � � p�''� SS <br /> Sfate and munry CKy,l/applrcable P/aca whem acttirred <br /> 10.If the inddent occur2d on a street or hlghway: <br /> N Y�" _ _ <br /> N�mcofshrefwhJghNvy AfUie7nWisecLoniNMorncvmsfinhrstthh.4�! �� <br /> i <br /> ,ill <br />