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i <br /> , <br /> R��`�'ED <br /> �v TORT CLAIM FORM SEP 0 3 2013 <br /> Pev.D7/09 <br /> Pursuant to Chapter 4.96 of lhe Revlsed Code of Washington (RQN), ��'�'�(OP EVB�ET�' <br /> this form Is for filing a tort dalm agalnst the Ciry of Everett. Some oF �+� Gyr �.,i� <br /> the InformaUon requested on tliis form. is requlred by RCW 4.96.020 �L ���` — <br /> and may be subJec[ to public disclosure. l'he Ciry Cleik Is the Gtys CIIyC7eN Clalm No. <br /> designated agent for the purpose of recciving dalms. C/a/m farms ��l}j ) ' (1 <br /> cannot be su�mlttod afectronica/!y(vfa e-ma(!or laxJ. '� <br /> Pl':EASk.`�R�iQ�tt!8xN1�;GL6A�SlY�INiINK .� .,. . .. �1;; ., �::.:C1, � :':: � `_'.' ;;r' I <br /> h1all or de�lver original slgned clalm torm M: Office of the City Clerk � <br /> City of Everett <br /> Businese Houre: 2930 Wetmore Ava.,Ste.l-A <br /> Mon.—Fri.,8 a.m.to 5 p.m.,PacificTime Everett,WA 98201 <br /> Closed on city holidays <br /> �LeZMANT INFORMATION: <br /> 1. Claimant's name: <br /> J �i ��On �(�bvr�� �-✓�n QS-CY-f -5!0 <br /> Last nvme Qirst �n NiOd/e Aate ofblrN(mrri/dd/yyyy) <br /> 2.CurrenFresldentlaladdress: ��0� f� t�.�e� I!"�l?� �� EvPi��-1- � 1.�R �$�� <br /> 3. Malling address(If dilferent): ---.- � <br /> 4, Resldentlal address at the time oF the Inddent(if dlfferent from current address): <br /> _ ! <br /> 5. Galman['s teiephone number. ��-�'aS��S�I-31$a �-1�S�u�(' (�11_ --. <br /> �.,J ^' Ham��- eq Q,VI�l_��us,l�(ss-�F✓ f <br /> 6. Cielmant'se-malladdress: u�p�Rs�s� �� v� �1'�r�2r.COM <br /> 1NCIDEdTINFORMAT[ON: <br /> O� �-: � 13 Time: (�o��0P``� <br /> 7. Datc of Inddent: ❑a.m, �p•m• (rheck one) <br /> �nvryddlriYYl <br /> 8, If the lnddent occurred over a peried of time,date of first and last occurrencest <br /> fiom: 71me:�_�i•m. U p.m,(check one) to_.___.____.Tlme: ❑a.m. 0 p,m.(check ane) <br /> (mM�d/vYYY) (mmrddlw,Vv) <br /> 9.Location of Incldent: S(1C�'1tlm�Sl� CU�n�_y____��JP�C'�'f" w� U� � <br /> Sfate vnd rouirty Ot�lfappl/cuble Placr whem aaumvl <br /> 10.If the Incldent occurred an a slreet or hlghway: <br /> A'anm olsfreel whighway At the 7ntersc�tbn wph orrrarcsf lntarni�rtg sfreel <br /> Rov.071U9 <br /> ll � <br />