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� .. Cllyol Ewratt U»Only � � <br /> . :: ,, _� , RECEIVED � � <br /> " �+� TORT CLAIM FORM <br /> q��.�,�,� ' SEP 16 2013 <br /> Pursuant to Chapter 4.56 of Ehe Revlsed Code of Washingtan (RC1N), �,'I�QF �tIE�E']"�' <br /> this form Is for hling a tort clalm agalnst the City oF Everett. Some of . , t� <br /> lhe in(orrnatian requested an thls form Is requlred by RCW 4.96.020 Cl� C�C�'f�. <br /> and may be subJect la publ(e disclosure. The City Clerk is the City's cirycionicaa�nNo:� "' <br /> deslgnajetl agent for the purpose of recelving claims. C/a/m forms �J�� � ���-f3 <br /> cannot be submiMed e%ctronica/ly(v/a e-maJ/or fax). ... ��1.1 <br /> GCao . _-YSo3 � <br /> FLEASE�AfF,�,,ORiP1�1�T�LEA�LY 1IN INIQ , +,it `: . ..;',;... , � :. ' r � <br /> ..��- . , .- . . , .. ::i ' _�u?} �.t� � t) <br /> Mail or deltver original stgned claim form to: Offica of tha Cfty Clerk <br /> Clty of Everck <br /> 8usiness Hours: 2930 Wehnore Ave.,Ste.1-A <br /> Mon.-F�I.,8 a.m:to 5p,m:;Pacific'Time Everctt,WA 98201 <br /> Closed an city holfdays <br /> CUIIMANT INFORMATION: i <br /> 1.Claimant's name: � ' <br /> ,,._._.(�IRt�.,� � . 7'R�u �YW 11�(316� <br /> �(astname . f'irst .. Pfiddlo . Dafe o/b;ifh(mm/ed/yyyyJ <br /> 2.Gurrent residentia!address: I�LS�.�5►��!' ►Q�L E <br /> 3.Mafling address(if different): <br /> 4:Residential address at the time oF the Incident(if dif(eront from current address): <br /> ___ _ ._ . <br /> S.Cfalmant$telephonenumber. ..-^ �as"34��`-53�8 . �-- � <br /> . . . . Nomc.. . . - ... - cel! � 6uslnesS. . - . <br /> 6,ClaimanNs e•mall addhc55: , TR�itEt'' ('�TFr� o� �(��w+i� Coryt _ <br /> INCI,D�NT INf0�hU1TI0N: <br /> 7.Date oF inddenr .�`���3 � .9����� 'Time:1�Rbr 6P� . ❑a.m. �.m, (check one) <br /> . (mm/dd/riYY) � Mjde�qk(' . . . 1 <br /> 8.If the IncldenF occurred over a pertod of tlme,da[e of first and last aaurrences <br /> from:.. -���- �� Tima ❑a.m. 0 p.m.(d�eck one) to Time: ❑a.m. 0 p.m.(check onc) ' <br /> .�(mm/ddlYV7Y7� ' (min/dtl//YYY) . <br /> 9,Location oF incident; .�A '.5�� H �V2�'e t'r /�{�SR�k.�CER IQ�(fi <br /> Sfateendmunry Gry,rfapplr�ab/e P/da°tYhereacrwred� � ����� - <br /> 10:If the inciden[oaurred on a street or hlghway: . <br /> �� - Nam,ofstreet or lUgAwvy Althe MG.vsecfion w/fh orneare.si Infasecflrr9 simet '- <br /> l <br /> S� <br />