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Ciy of Everett Usa Only <br /> RECEI��� <br /> TORT CLAIM FOI�M <br /> SEP o 5 2�t:3 I <br /> f1av.07/Of <br /> Pursuant to Chapter 4.96 oF the Revised Code of Wasliington (RCW), C�TY OF EVE[�E�'Z <br /> this farm Is for filing a tort claim against the City oF Everett. Some oF C'�}�� C,�,t.�_ <br /> the information requested on this form is required by RLW 4.96.020 'l <br /> and may be subject to public disdosure. The City Clerk is the City's �M cicik C�anu r,a_ _.. _ _______ .--__ <br /> d�ignated agent for the purpose of receiving claims. C/�im forms __Jr�� I — (�j <br /> canno[be suLmitted e%ctronica//y(via e-mail or faxJ. � <br /> PLEASEffYPEORPRIM*'CLEARLYc�ININK . ' . ` .: . ' ; <br /> Mail or deliver originat signed claim form to: Office of the City Clerk � <br /> Cily of Everett � <br /> Business Nours; 2930 Wetmore Ave.,Ste. 1-A <br /> Mon.—Fri�,8 a.m,to 5 p.m.,PaciFic Time Everett,WA 98201 � <br /> Closed on city holidays I <br /> CLAIMANT INFORMATiON: <br /> 1. Gaimant's name: { <br /> ��a .�r �Cw I �'f�.S�M �ti//S'/�`�/S �/ <br /> --�'---`-- — � <br /> Caslname First M/dd/e Dateofblrth(mm/dd/yyyyJ <br /> 2. CLrrent resldential address; I S�� �c vc%��• j9� ��P+e"� W,/g J�o��� <br /> 3, Malling address(if different): ___!_ <br /> 4. Residential address at the time of the Inddent(if difFeren[from curren[address): <br /> 5.Claimant's telephone number: _ ___ p5 ���' ����' _ _ <br /> Home , Ccl/ Bus/ness <br /> 6.Claimant's e-mail address: Cf`rC,c, , GJ z�P .5 � �__��� �+n,a _ _ <br /> � T-- <br /> INC[DENT INFORMATION: <br /> 7. Daie of incident: _���_) a'��3 __, Time: _ ._ ❑a.m. �p.m. (check one) <br /> (mnVJdJyVyy) <br /> 8.If the incident occuRed over a period of Nme, date of first and last o�currences: <br /> from:______,.__. Time: _______ _O a.m. lJ p,m.(check one) to______Tlme: ❑a.m. 0 p.m.(check one) <br /> (mm/4tl/yyyy) (mm/Ad/yyyy) J <br /> 9. Lacation ot incident: �V R __.:))���_a�1�5�� ��[�C�-- - —((�j�,re [�c(i(4PSs) I <br /> s7afa and mun[}� Ciry,/frpp/kaGle Plece whcre ocrurred <br /> 10. If the incident occurred on a street or highway: <br /> /.s�� R�� ���.- ��� �,���+_t_�1�� _ I <br /> Name olstmM ar h.�qhwuy At fhe/nfeactl/a�x•iflr wvuvresf/ulcuet!lqq,lnrf I <br /> Rev.07709 /J � <br /> �/Jot{�/�1% 0 /.�.k�riY,f�/� <br /> � Z <br />