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05*6r <br />TORT CLAIM DORM <br />no.'. Dr/03 <br />Purs.int to Chapter 4.96 of Ore Revlstl Code of Washington (RWi), <br />this form Is for FlNrg a tart claim against the City of Everett. some of <br />the Information requested on this form is required by RCPJ 4.96.020 I <br />and may be subject to public disclosure. The City Clerk is Ore City'ss <br />designated agent for the purpose of receiving claims. 6117 <br />1m forms <br />cannot be submlttod efectronlcally(vfa a -malt or fax). <br />OCT 0 1 All <br />CITY OF EVERETT <br />City Clerk <br />("Ip C .rid C'n m h'i <br />r ,m ._ t'z <br />r rr <br />fPSFASE'1'' . ORPAR— IIV r. LEARI`v:�LLNK.L._. -_ •_', '' �_:.,:• ;t_" <br />Mail or deliver original signed claim form to: <br />Business Hours: <br />Mon. —Fri., 8 a.m. to 5 p.m., Pncific Time <br />Closed on city 11011days <br />CLAIMANT INFORMATION: <br />I. Claimant's name: <br />Office of the City Clerk <br />City of Everett <br />2930 Wetmore Ave., ite. 1-A <br />Everett, WA 98201L <br />Ja5in9me r�hrsf I'MIXee AM 07 D144(mrgrayyypy/ <br />2. Current residential address: —2 /(.Owrl e I el—p <br />3. Mailing address (If dlffcrcnt): gal (o <br />4. Residential address at the time of the Incident (If different from current address): <br />5. Claimant's telephone number. _—[14'L 419S/ 3.V 7 " "S� !;2 2�Z PW <br />Nome cell Ou3i7ra <br />6. Claimant's e-mail address: --- <br />INCIDENT INFORMATION: q <br />7. Date of Incident:y�) _. Thne : _ _ ❑ a.m. �(p.m: (check one) <br />(mDyddJ%YV <br />8. If the II CI enntL'PPCFurred over a period of time, dale of first and la 1p�ae s: `'! <br />from: m .3 Time: ❑ a.m. f r.m. (check one) 2-0-1 l 71nic: tl a.m. y`i.m. (check one) <br />(mm/ddlyyyV) „ t (mnVddJlyri/) <br />9. Location of Incident: <br />Stateandcvunty OryS,lapplCal"e Were ahem occurml <br />10. If the Incident occurred on a street or highway: <br />nith <br />Rev. 07100 <br />