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RE�C�E�UV�� <br /> TORT CLAIM FORM SEp o s 2013 <br /> Nor.07/09 <br /> Pursuant to Chapter 4.96 of lhe ReNsed Code of Washington (RCW), C!'FY OF EVERETT <br /> thls Porm Is for filing a tort clalm ac�alns[the City o(Evcrett. Some of cih ci� <br /> the Informatlon requcstcd on thls form Is mqulrcd by RCVJ M1.96.020 <br /> and may be subJect lo publlc Alsclosure. The Ciry Clerk Is ihe City's aryc�eneaaimno. <br /> designated agent for the purpose of recelving dalms. C/a1m/orms 3 — � <br /> canno[bestrbm/ttede/eclronlcalty(vlae-ma!/orlaxJ. C 3�. G <br /> P.L'EqSE7YREORPRiNT�CLkARCY:iIN%INK ' ' � � � <br /> Mail ordeliver origlnal elgned claim fonn to: Offico of tho City Clerk <br /> [fty oF Everott <br /> Buslness Hours: 2930 Wetmore Ave.,5[e.1-A <br /> Mon.—Fri.,8 a,m,to 5 p.m.,Pac{fic Tlme Everett,WA 98201 <br /> Closed on clty holidays <br /> C�'�JQ�JT YNPORMATION: <br /> 1,Clalmant's namc: <br /> _ -�U.���n=. �rr-� �r�� �D��ix-n� S-�f- l`3SG� <br /> [ast name �� � fNsi M/dd'e IkM albMh(mrq/dqiyyyyJ <br /> 1�z(-� I� ' <br /> 2.CLrmnt resldcntlal address: t� e� �v¢ �,�e�r- �(� � L�(��- `i�<�Cil <br /> 3.Mailing adAress Qf dlfferent): <br /> 4.Reslden0al address at the tlme of the InUdent pf different from current address): <br /> S.Clalman['stelephonenumber =1��5 -���� �il�'.� `l�S ��l�l I3��-I <br /> � Hamc 7tin r� CL�// Bus/nc.cs <br /> 6.Clalmant's c-mall address: r.� ��Ca��,r�n�y�t�r� �1"JUn�l C'.�•CO^� <br /> INCIDENTINFORMATION: <br /> j?���`�� r� <br /> 7. Date oFlnciden[: �>`� ��' 1�� Time; "� � � ❑a,m. ❑p.m, (check one) <br /> c�vaam�v) <br /> 6.lf the Indden[ocaured ovcr a perlod of tlmc,datc uf flrs[and�ast otcurtences: <br /> (rom: Tlme: ❑a.m. 0 p.m.(check one) to Tlme: ❑a.m. 0 p.m.(chttk ane) <br /> (mryddlf1lY) (mnydd/yy�y) <br /> 9.LocaUanoflnddenL• •�ncll,cr+��c�l� U1rY mu ��Yime ��(��� n-r-�, (��- <br /> Stafi and rounry ary, "opp7ca61e �T Plare tvhem envrted (-�v1��'E�,L"� <br /> 10.if the�ndden[occurred on a streel or hlghway: , <br /> � Nanma/shcrtorh/ghrvay AlfhelnMrsttNan�v!lhorncumstlrtfersrctln9slice7 <br /> Rov.07l09 <br /> �2 <br />