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Clry of Evemit Use Only <br /> n' TORT CLAIM FORM R�,C��V�� <br /> Per.0//Of <br /> Pursuant to Giapter 4.96bf lhc Revlsed Codc�of Washington(RCW), SEP 16 2013 <br /> thls form Is for filin9 a IoK.dalm a9alnst the City of Everelt. iome of . <br /> the Iniormalion requested on this (orm Is required by RCW 4.96,020 <br /> and may be subject to public disdosure. The City Clerk Is the City's r�t � i c �n , <br /> desi9naled aycnt for lhc purpose of iecciving daims. duim(onns �{��1�..1. <br /> cannatGee��bmRtedelectronicalty(vlae•nrailor�fixJ. aJ� R�' <br /> , �. <br /> PLEASR:7YI!E'OR;PRiNT�:CLfqRLY'•TN;INK�; S� :' . . � �. �.c.ai'.1D130D��'ISOI '`���'- <br /> Mail or dclivor ori�inal sl�nnd claim form to: O(licn of the City Clork <br /> City of Everelt � <br /> Business Nours; 2930 We[moro Avu.,S[e.1•A <br /> t�on.-FA.,II a.m. l0 5 p.m.�PaciFlc Time Evcrelt,WA 9U201 <br /> Closed on cily holidays <br /> CLAIMAfVT INFORMATION; <br /> 7.Clalmant's name: <br /> N t.cl,�eir�.hor I�oo c��;[t��5«^. - w�4��,`1�+�LP�. J-ou_�6�,_c°IAci� S-a� w�e U <br /> cesrn.,�m� � knsr ' 1 ruddi� a�m o�baKn(mn�edMyy) <br /> 2,Currenlresldentialaddress: ��_��2u��CC�_� � �y�� �JQ�8�01 ___�^ <br /> �r"1'd--�- y: -- <br /> 3.Malllr9 address pF tlifferen[): _____.._. __.—__—__—__�.___—_.--�__. <br /> 4.Resldentlal address at the tlmc of the IndAent(I(Jlfterent from current addrefs): <br /> S.Claiman['stelephonenumber: !},� -s .3za_��9"1 4�5-i�7•'�IS_� 4cZ7'3A8-9�1'iS_ <br /> Honm Cdl � 6us+'ncts <br /> 6.Cl�dinan['s e-mall address: _y]y.,�lfytve-11'E�«+n�I[�i•,. ____ ________ <br /> ujCIDENi I[yFOg+�TION: <br /> 7,Date o(indden[: GZ a1'I�U�4. __ Time: �+>>w____ �a.m.�-p•m. (check one) <br /> pnn/na/yyry) . _- <br /> e.1f Ihe incident uccuned over a period of Qmc,date o(first and last o:cmrences: <br /> 6nm: Tlme: U a.m. 17�.m.(check one) to_ Tlme: Il a.m. 17 p.m.(check one) <br /> (ninirJd/Wf/) (imnJAJ/11YY! <br /> 9,la�aUono(Inddent: _�:t5�dit2^'�.UYI.�_Sn4Hwn�• � _�ve�,�}'rJ��1 �.�.aL✓.,/��l�Q,._._-- <br /> Sf�M and�unly [Yly,I/.�PpNrub/c Matc�vhcre occuned <br /> 10.If the Incldent occurred on a street or hl9h�vay: , <br /> ...---' Mrrtmnl.Vnr.�tnlrp8ixty"----�._��..---"'-"...— ANhnGrho>crlMnrnll�rvne�iresl/Mrrsx(Gr�elrtrl' . ._.---- <br /> Ruv.01109 <br /> Y ,1 � <br /> �_/ <br />